Fillable Nursing2 Assignment Student Client’s Initials (Orange County Community College)

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Nursing2 Assignment Student Client’s Initials (Orange County Community College)

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Student _____________________________________ Client’s Initials___________________
Date____________________ Age______________
Medical Diagnoses_________________
Date of Admission_________________
Nursing II - Assignment - ASSESSMENT (DATA COLLECTION)
PHYSIOLOGICAL:
OXYGEN: Cardiovascular Respiratory
Skin warm to touch?_________ Respiratory rate_____________ Rhythm____________
Skin color________________
____ Audible breath sounds_____________________________________
Color of nail beds____________ Dyspnea - at rest on exertion
Temperature_________ Location_____
_____ Cough Sputum_______ None
Radial pulse rate ____ Rhythm _____ Smokes Packs per day______
Apical pulse rate_________ Rhythm ___________ * Medications_____________________
BP: Location_ _________ Position _ ________
_____ Laboratory data _____________________________
Peripheral Pulse________
Pulse ox__________ Equipment in use (O
2 ,
flow rate)_______________________________
Pain Scale # Numeric □ Faces □ Additional data:
Capillary Refill ______
FLUIDS AND ELECTROLYTES:
Skin turgor - Normal Poor Presence of thirst some, does not drink water
Tongue and lips__________________ Nausea or vomiting
Mucous membranes______________ Presence of edema none
Fluid intake for previous 24 hrs _______
*Medications_______________________________________________
Fluid restriction (Note amt q 224 hrs &
distribution q shift) Laboratory data ____________________________________________
Equipment in use __________________________________________
Additional data:
NUTRITION:
Ht_____________ Wt ______________ Dentures? Upper Lower Partial
Ordered diet___________________________ Recent change in weight? ______
Preferred foods______________________ Problem chewing? Swallowing? Heartburn? Indigestion?
% of meal consumed_________________ *Medications________________________________________________
Dietary supplement ________________ Laboratory data_____________________________________________
Assistance with meals ______________
Equipment in use (N/G tube, PEG tube, G tube, etc.)________________
Additional data:
ELIMINATION:
Urinary: Bowel sounds________________ Abdominal distention
Amount___ ___
Color________ Frequency _______ *Medications___________________________
Bathroom Commode Bedpan Incontinent Laboratory data____________________________________
Total output for previous 24 hrs______ ml Equipment in use__________________________________________
Bowel: Amount_______
Color________ Frequency______ Additional data:
Normal for client Constipated
Diarrhea Incontinent
MOBILITY AND ACTIVITY: Fall Assessment Score_______________
Muscle strength - Handgrips equal Fall risk - High Moderate Low
Foot pushes equa l Physical therapy working with client?_____________________
ROM - Normal Limited Severely limited *Medications______________________________________________
Ability to move in bed - Self Assist Immobile Laboratory
data____________________________________________
OOB - Chair Wheelchair Geri-chair Equipment in use (assistive devices)___________________________
Ability to transfer - Self Assist__________ Additional data:
Distance able to ambulate ________
Gait_______
REST, SLEEP AND PAIN:
Reported quality of sleep in hospital_____________ Observable signs of pain - Grimacing Posturing Moaning
C/O Pain - *Medications_____________________________________________
Location __________________________ Pain Scale # Numeric Faces
Intensity__________________________ Additional data:
Duration_________________
SAFETY AND SECURITY:
Vision: Skin integrity:
Able to see without glasses Needs glasses Intact
Able to read own menu Reddened Location_______________________
Watches TV from _____ ft Blancing erythema Non-blancing erythema
*Medications_______________________________ Incision/Lesion/Wound Location_________________
Approx. size in cms_____________________________
Hearing: Appearance___________________________________
Responds to normal voice tones Treatment (dressings, etc.)________________________________
Hearing aid Deaf *Medications___________________________________________
Speech: Allergies_________________________________________________
Clear Garbled Incomprehensible Laboratory data___________________________________________
Mental status: Environment:
Alert Lethargic Unresponsive Physical surroundings_________________________________
Oriented to - Person Time Place *Medications___________________________________________
*Medications_______________________________
Braden/Norton Score # ________ Risk: High Moderate Low Additional Data:
LOVE AND BELONGING:
Client report of family/friends____________________ Next of kin (chart)_________________________
___________________________________________ Religious affiliation________________________
Indicators - Cards Flowers Family pictures Additional data:
SELF-ESTEEM:
Family role ________________________
____________ Grooming equipment at bedside:
Occupation_________________________ Brush/comb Toothbrush Toothpaste
Interest in appearance_____________________ Other personal toiletries
Additional data:
SELF-ACTUALIZATION:
Client report of satisfaction with life _______________ Additional data:
____________________________________________
Independence_________________________________
Creativity____________________________________
ERIKSON’S STAGE OF DEVELOPMENT:
The client is at the following developmental stage and explain why:
*Always include name of medication, dose, route and time.
assessment NSG II
FORMAT FOR CLINICAL PAPER USING THE NURSING PROCESS
(Use one sheet for each nursing diagnosis)
NURSING DIAGNOSIS
INTERVENTIONS
RATIONALE
(NANDA Approved)
(Must relate to 2
nd
part of this Nursing Diagnosis - BE
SPECIFIC )
Align each intervention with the rationale
1.
( Must be scientific and specific to client)
(Give reference and page of rationale)
which explains the intervention.
1.
DEFINING CHARACTERISTICS
(Assessment data for this
client
which supports this
Nursing
Diagnosis)
Please list, i.e., #1
#2
etc.
EXPECTED OUTCOME
Evaluation
(One outcome per diagnosis)
(“The client will....(measurable -
include evaluation criteria)....as
evidenced by....(date/time -
realistic time frame)”)
Must support the 1
st
part of nursing
diagnostic statement.
a:table.5 in clinical assignment NSG II 04 (25)
FORMAT FOR CLINICAL PAPER USING THE NURSING PROCESS
(Use one sheet for each nursing diagnosis)
NURSING DIAGNOSIS
INTERVENTIONS
RATIONALE
DEFINING CHARACTERISTICS
EXPECTED OUTCOME
Format for clinical paper using the Nursing process 9 04 (25)
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Nursing2 Assignment Student Clients Initials (Orange County Community College)

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Completed 18 July 2020

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