Southville International School and Colleges

1281 Tropical Ave. corner Luxembourg St., BF International, Las Piñas City
Tel. No.: 825-6374, 820-8702 to 03; Fax No.: 820-8715

SISC/QSF-NSG-068 Rev 000 4/19/10

COLLEGE OF NURSING

Name of Student: _______________________________ Level: _____________ Inclusive Dates: _______________________________

Clinical Rotation at: _______________________________

ON-GOING ASSESSMENT IN CLINICAL SETTING

Patient’s Name: _________________________ (Initials Only) Allergies: ___________________________________
Attending MD: _______________________________________ Diagnosis: ___________________________________

VASCULAR ACCESS
BR IV #1
Dangle
Chair IV #2
Amb
Type of Activity
BRP
ACTIVITY

BSC IV #3

How Accomplished Self SAFETY Bed in Lowest Position

With Asst
Turn and Position Self Call Bell Within Reach
Q2o Assisted Seizure Precautions
Range of Motion Passive Aspiration Precaution
Active Initials
Deep Breath and
Cough
Bed Bath, Shower Self
SKIN BREAKDOWN SCREEN/BRADEN SCALE
(Circle One) With Asst
Complete 1. Completely limited
Sensory Perception
HYGIENE

Oral Care 2. Very limited

Ability to respond to
Peri Care 3. Slightly limited
Discomfort 4. No impairment
Sitz Bath
Cath Care (Q Shift) 1. Constantly moist
Moisture – degree to
Linen Change 2. Very moist
which skin is exposed to
PM Care 3. Occasionally moist
moisture
4. Rarely moist
NPO 1. Bedfast
Self Feed Activity – degree of 2. Chairfast
Meals Taken By 3. Walks occasionally
Asst/Supervision physical activity
NUTRITION

Total Feed DATE: 4. Walks frequently

100% 
No Problems 1. Completely Bowel sounds normal,
Amount of Meal(s) Identified abdomen soft, non-tender and non-
50% Mobility – ability to immobile
Taken distended
Less than 50% change and control body 2. Very limited
3. Slightly limited  Firm  Hard
Abdomen  Soft
Per Order position  Non-tender  Tender
Supplements Taken
GASTROINTESTINAL

Refused 4. No limitations
 Non-distended  Distended
Void ad lib Bowel Sounds 1. Verypoor
Normal  Hypoactive
ONELIMINAT

Foley Cath 2. Probably

 Hyperactive  Absent
Nutrition – Nausea
usual food  No  Yes
Urine Incont inadequate
intake pattern
Vomiting  No  Yes
Incontinent 3. Adequate
Stool  Normal
4. Excellent  Constipation
 Diarrhea  Tarry
Incontinent 1. Problem
Stools  Incontinent  Bright Red
# of Stools 2. Potential problem
Friction andGIShear
Tube Type 3. No apparent
Chest Tube To suction
R or L Off suction problem
Total ScoreOstomy Type
TUBES/DRAINS

Suction
Drains Type: _______
Clamped Signature GI Comments
Suction
No Problems  Urine clear/yellow,
NGT Clamped NOTES: Identified denies any reproductive problems
___________________________________________
Placement/Residual
Suction (Enter # Trach ____________________________________________
Urine Color  Yellow  Amber  Bloody
GENITOURINARY

Times/Shift) NT ____________________________________________
Character  Clear  Cloudy  Clots
Oral ____________________________________________
Voiding  Contingent  Incontinent
Initials ____________________________________________
 Frequency  Urgent
 Burning  Anuria
____________________________________________
GU Tube Type  Foley  Suprapubic
_______________________________________________________________________________________________________
 External  Urostomy
_______________________________________________________________________________________________________
Female Vaginal  No  Yes ___________________
Drainage
DAILY GUIDE: Male Penile  No  Yes ___________________
Day 1 → Assessment, Gather Data – Identifying Problems Discharge
Day 2 → On-going Assessment – Prioritize Problem – Set Goals – Interventions
GU Comments
Day 3 → On-going Assessment – Interventions – Outcome/Evaluation
No Problems  Normal affect, intact
Identified thought processes, understands
DATE: hospitalization/tx
A LP S Y C H O L O G I C
NEUROLOGICAL

No Problems  Alert, oriented x3, Affect/Mood  Normal  Angry/Hostile/Agitated

Identified speech clear, strength equal in all  Flat/Withdrawn  Unable to
extremities, pupils equal and reactive Assess
LOC  Alert  Coma  Intact  Unable to assess
Thought Processes
 Lethargic  Obtunded  Abnormal Finding: _______________
Insight  Understands hospitalization/tx
Orientation  Person  Place  Time
 Does not understand
Speech  Clear  Untestable
hospitalization/tx
 Slurred  Aphasic
 Unable to assess
 Mute
Psych Comments
 Dizziness  No  Yes
Ataxia  No  Yes
Pupil Reaction R  Brisk  Sluggish  Fixed
L  Brisk  Sluggish  Fixed
Vision  Clear  Blurred  Fixed
Extremity Strength RUE  Strong  Weak  Flaccid
LUE  Strong  Weak  Flaccid
RLE  Strong  Weak  Flaccid
LLE  Strong  Weak  Flaccid
Neuro Comments
No Problems  Normal heart sounds,
Identified regular rhythm, color pink, skin
warm/dry, no edema
CARDIOVASCULAR

Rhythm  Regular  Irregular

Heart Sounds  Normal  Abnormal
Skin Color  Pink  Pale  Dusky  Flushed
Skin Temperature  Warm  Hot  Cool  Cold
Edema  None  Yes, location:___________
Capillary Refill  Brisk  Prolonged
JVD  No  Yes
Pulses  Radial and Pedal Pulses Present
 Abnormal Finding:_______________
CV Comments
No Problems  No distress, lungs clear
Identified bilaterally, no cough
Respirations  No Distress  Dyspnea
R  Clear  Rhonchi
 Wheezes  Crackles
RESPIRATORY

 Diminished  Absent
Breath Sounds
L  Clear  Rhonchi
 Wheezes  Crackles
 Diminished  Absent
Cough  None  Dry  Productive
Sputum  None  Clear  White  Green
 Yellow  Brown  Bloody
O2 Device  None  NC  Mask  Collar
Artificial Airway  None  Trach
Respiratory
Comments

HIGHLY PRIORITIZED
Nursing Problem: ______________________________________________________________________________
CARE PLAN
Nursing Diagnosis Related Drug Related Lab Short Term Goal Nursing Intervention Evaluation/Outcome
Therapeutics Diagnostics

CRITERIA: Content / Completeness - 45% Accuracy - 40% Punctuality - 15%