17Short Form Care Planning Tool: RAM Assessment of Behaviors & Stimuli
Student Name: Allyson Simmons
Date Assignment Completed: 9/1/2022
Client (Code)
Age 85
Primary MD Dr.
Williams
CODE Status Full Code
Primary Diagnosis Left hip fracture
Past Medical History
Past Surgical History
Osteoporosis
Hysterectomy 20 years
ago
Vital Signs: Within normal
limits
Time 0800
T (route) tympanic 99
Hysterectomy
AP
Dizzy spells
B/P 128/76
R
Arm position __right
arm_________
R 14
O2 Sat 97
___x_ Room air
______ Oxygen therapy
Devise
____ l/ min
Comments:
No known past family medical history
Seizures
Stomach
Ulcers
Stroke
Mental Health
Problems
Kidney
Problems
Hypertension
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Environmental
Allergies
Anemia
Relationship
Cause
of
Death
(if
applicable)
Alcoholism
Family
Medical
History
Age (in years)
Pain: (0-10) 2
Current Medications (Including Herbal & Over the Counter)
Medication
Route
Dosage
Frequency
Enoxaparin
Subcutaneously
40mg
Daily
Docusate
PO
100mg
Daily
Morphine sulfate
IV
4mg
Every 4 hours prn for pain
Raloxifene
PO
Not listed
Daily
Immunization History:
All immunizations up to date
Admission date: 9/1/2022
Height: 152 cm
Weight: 47.5 kg (105 lb)
BMI: 17.47
Allergies: (Including environmental, food and medications) NKDA
Name of Agent
Reaction
System
Review Findings
GI/Nutrition
Diet: Appetite 65%

-
-


Normal Findings:
Bowel sounds active in all quadrants Abdomen soft,
non-distended, non-tender Receives and tolerates
nutrition and fluids
Absence of nausea, vomiting, cramping, diarrhea or
Constipation
No complaints of nausea, vomiting, or abdomen
pain with palpation
How did you assist the client with their diet? Asking
what food, the patients likes to eat
Asking what are the patients preferences
Describe your Findings:
Patients eats very little with no nutritional value
Feeding tube (include size and type)
Assess barriers to accessing nutritional food
Intake: 575 ml
Neurological

Normal Findings:
Alert and oriented x 3
Speech is clear
Memory intact
Follows commands and converses
Absence of seizures
Behavior appropriate to situation
When upright: Balance steady Gross motor
coordination intact
Hand grasps strong/equal
PERRLA,
Foot presses and pulls strong and equal
Gag, cough, blink reflexes intact
Patient denies numbness tingling or other
paresthesia of extremities
Respiratory

Normal Findings:
Breath sounds clear and equal in all lobes.
Respirations regular, non-labored, without
use of accessory muscles
Mucous membranes pink
Chest excursion symmetrical
Trachea midline
If cough present, non-productive
Sputum clear or absent
Cardiovascular

Normal Findings:
Regular rhythm, heart sounds S1 S2 present
Blood pressure baseline
Denies chest pain
Periorbital, sacral, pedal & generalized
edema absent
Skin warm & dry to slightly moist
Nail beds pink, capillary refill< 3 sec
Peripheral pulses palpable or present with doppler
Skin

Normal Findings:
Color normal for ethnicity
Temperature warm, dry to slightly moist
Turgor normal, mucous membranes moist
Skin intact without breakdown, rash,
redness
Describe your findings:
Patient denies any dizziness and nausea at this time.
Pupils are both 5mm in size, equal, round, reactive to
light with constriction to 3mm. Mini- cog assessment
was performed with patient verbalizing 3 words,
filling out the clock correctly, and repeated 3 words
mini- cog score of 5/5. GSC shows Spontaneous
opening of eyes obeyed verbal commands conversed
oriented GCS score 15
Describe your findings:
Normal heart and lung sounds anterior and posterior
Describe your findings:
Normal findings on auscultation
Describe your findings:
Skin intact with normal elasticity
Wounds

Normal Findings:
Edges approximated and clean
Surrounding tissues free from signs &
symptoms of infection
Dressing dry & intact: drainage absent
IV Site (If applicable)


Peripheral IV:
Site
Size
Date Inserted
Fluids infusing yes/ no
• Type
• Amount
If no fluid, last time flushed
Central Access Device:
• Type of Device
• Date inserted
Fluids infusing- yes/no
Type
Amount
Mobility/Functional Ability




Normal Findings:
Active ROM of all extremities within physical
limitations
Tolerates prescribed activity order
If ambulatory, gait steady
Able to complete ADL's
Able to transfer (with/without assistance)
List assistive device(s)
Determine if assistive devices are used correctly
Neurovascular assessment for client with cast or
traction
GU/Elimination


Normal Findings:
Urine clear, straw to amber no unusual odor
Urine output within established parameters
Bladder non distended
Continent or incontinent of urine
If urinary devise is used, list (indwelling
urinary catheter, external female catheter,
condom catheter, suprapubic catheter,
straight catheter)
Wounds: (yes/no?) Findings:
NO
IV/ Central line (yes/no?)
Describe your findings:
IV intact and patent
Right hand
18 gauge
9/1/2022
Lactated Ringers 84 ml/hr
Describe your findings:
Limited ROM reduced muscle strength unable to
move or transfer independently
Patient has a walker and cane that she does not use
Gait unsteady
Describe your findings:
Patient is continent uses bedpan due to hip fracture
Output: 600ml
Psycho-Social




Normal Findings:
Participates in two way conversation, care and
treatment plan
Able to communicate his/her needs
Coping mechanisms intact (client and family)
Mood/affect/behavior appropriate to situation
Assess client’s definition of health
Assess client’s understanding of current illness
What are the client’s resources for healthcare access,
access to housing and food, ability to afford
medications/ services and transportation to follow-up
and future healthcare visits?
Pain, Comfort, Rest and Sleep





Normal Findings:
Rates pain ( may use numeric scale 1-10, WongBaker faces pain scale, FLACC scale, CRIES scale,
color analog scale, etc)
States and appears rested
Rests/sleeps during shift
Slept well during night
Obstetrics (If applicable)

Assess Maternal status
Description of uterine activity
Assessment of Fetal status
Description of findings on vaginal exam, if
performed, including cervical dilation and
effacement, fetal station, change in status of
membranes, and progress since last exam
Postpartum (If applicable)

Describe your findings and identify scale used:
Initial pain was 8/10 the pain decreased to 2/10 after
pain medication given
Describe your findings:
Post Hysterectomy 20 years
Describe your findings: N/A
Assess Postpartum status
Assess the breasts
Assess Uterus (firm or boggy)
What is the fundal height
Is there bleeding (color and presence of clots)
Inspect the dressing and incision if C- Section
Assess Lochia (color, amount, number of pads
used)
Inspect the episiotomy ( redness or drainage)
Has the client voided (amount, color)
Has the client had a bowel movement
Assess bonding
Newborn Assessment (If applicable)

Describe your findings:
Socially withdrawn
Assess Newborn status
APGAR ( Appearance, pulse, grimace, activity
and respirations)
Weight/Length
Head and abdominal circumference
Skin (color, texture, nails, presence of rashes)
Head and neck (molding)
Fontanels
Genitals and anus (passage of urine and stool)
Describe your findings: N/A
Pediatric Assessment (If applicable)

Safety: Describe your findings:

Describe your findings: N/A
Assess Pediatric status
Assessment triangle (general appearance, work
of breathing and circulation of the skin)
Psychological, psychosocial and physical
development aligned with age
Normal Findings:
The physical environment is safe.
• Physical layout of client area
• Alarms
• Bed, IV
If Restraints used : Describe care
Normal findings call bell within reach
Current order for restraints
Identify Focal Stimuli (Focal stimuli, according to Roy (1983) are those stimuli that immediately confront the
individual in a particular situation. Example: Individual needs, the level of family adaptation, and changes in the
family environment.
Patient lives alone and is socially withdrawn. Struggles with independence and refuses help from family
members
Identify Contextual Stimuli (Contextual stimuli, according to Roy (1983) are internal or external factors that
influence the ability to respond to the focal stimulus and contribute directly to adaptation but are not the focus of
attention and energy.) Example: Other stimuli that may influence the situation- Coping mechanisms, diagnosis,
symptom severity and co-morbidities.
History of osteoporosis unsteady gait recent dizzy spells
Identify Residual Stimuli (Residual stimuli, according to Roy (1983) are the additional environmental factors
present within the situation but whose effect on the client is unclear. Example: Beliefs, behaviors and personal
experiences.
Age, weak bones, refusing to use assistive devices, resistive to assistance
Diagnostic Testing/Laboratory Data (CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.)
HTC 42% WBC 18 Platelets 195
X-rays show left intertrochanteric hip fracture
Teaching Needs Identified during the assessment (Behavior & Stimuli): Assessment of readiness to learn will
be completed as part of the Teaching Plan.
What teaching was reinforced during interactions with the client? Use of walker and cane / Dietician
consulted
SBAR Report
Situation
Patient having bouts of dizzy spells with an unsteady gait Patient had a fall resulting in a left hip fracture
Background
History of osteoporosis patient lives alone and refuses help from family
Assessment
Poor nutritional values patient feels loss of independence and refuses to use assistive devices
Recommendation
Consultation with a dietician and rehabilitation and provide information for social groups geared to
patients age
Professional Nursing Care Plan
The following table provides information to utilize in developing your nursing care plans. Each column in the care plan form should include the appropriate information
related to the Nursing Diagnosis. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as noted on the page below. The Nursing
Diagnoses are then labeled in priority order where 1 would be the highest priority. (Nursing Diagnosis Priority #
) Any questions that you have concerning
the nursing care plans should be directed to your instructor.
(I) Data Collection Related to the
Nursing Diagnosis
Subjective
(Nonobservable)
Objective
(Observable)
Subjective data
should be clear,
concise and
specific to the
Nursing Diagnosis
Objective data
should be clear,
concise and
specific to the
Nursing Diagnosis
Subjective Data:
Objective Data :
What the patient or
family relates,
states, or
reports. (Nonobservable)
What is observed or
measured. May
include the client’s
behavior, vital
signs, lung sounds,
urine output,
laboratory data,
diagnostic testing
(etc.) as related to
the specific nursing
diagnosis.
(Observable)
1.
2.
3.
4.
(II) Complete NANDA
Nursing Diagnosis
(IV) Nursing
Interventions
(V) Scientific
Rationales
Best Evidence with
References
(VI) Evaluation of
Patient
Goals/ Outcomes
Choose a NANDA approved diagnosis.
The statement should list only one diagnosis and listed in the
following format, i.e., problem followed by "Related to (R/T)
the disease process
Manifested by: (signs and symptoms) is not part of nursing
diagnoses and should be written as a separate line.
Example: Coping, ineffective family: R/T Temporary family
disorganization and role changes. Manifested by significant
other's limited personal communication with client.
Each statement should be supported by a rationale
Should be:
1. Concise
2. Clear
3. Specific
4. Individualized
5. Accomplishable to
client and/or
family, significant
other.
1. Rationale should
address how
interventions are
going to solve the
problem and/or attain
the outcomes.
2. Rationale should be
specific to the
interventions, i.e., why
giving morphine 10
mg IV, why the client
is being turned and
positioned in proper
alignment every 4
hours.
3. Rationale can be
summarized in own
words and/or quoted
verbatim from
sources.
4. For every nursing
intervention, there
needs to be a
rationale.
Should address:
1. If the expected revised,
state how would revise
intervention.
2. What was the client's
response to
interventions?
(III) Goals/Outcomes
(Long and Short term) Including
timelines/timeframes
1.
Could have both short term and long term outcomes throughout
Nursing Care Plan (NCP), but each client should have one long
term goal as part of the NCP.
Definitions:
Short-term goals: Those goals that are usually met before
discharge or before transfer to a less acute level of care.
Long-term goals: Those goals that may not be achieved before
discharge but require continued attention by client and/or
significant others as indicated.
2. Each diagnosis, if appropriate, could have short-term goals and
long-term goals.
3. Statements:
Specific - relates to nursing diagnosis.
Measurable - tells what to see, hear, or smell.
Achievable - realistic for patient.
Clear and Concise - don't use “increase” or “decrease” without
giving baseline range of data.
4. Timelines (timeframes) for
achievement of goals:
Should be realistic and specific.
Give a date or time at which the expected outcome and nursing
interventions are achieved and/or evaluated.
Should specific as "by discharge date" or "on going."
Student Name: Allyson Simmons
Client Code: Full Code
Instructor: _____Mrs. Loesch
___________________________
Date: 9/30/2022
Nursing Diagnosis Priority #
Grade:
Professional Nursing Care Plan
(I) Data Collection Related to the Nursing
Diagnosis
Subjective
(Non-observable)
Unable to move or
transfer independently
Difficulty using the
incentive spirometer
(II) Complete NANDA
Nursing Diagnosis
(IV) Nursing
Interventions
Objective
(Observable)
Vital signs
B/P 130/80
Temp 97.2
SPO2 94% at room air
HR 85 bpm
Capillary refill 2 sec
Pedal pulses within
normal limits
Impaired Physical
Mobility
Risk for impaired gas
exchange
Teach patient or assist
with active and passive
ROM exercises
Encourage the use of
isometric exercises of
affected and unaffected
extremities
Assist with incentive
(III) Goals/Outcomes spirometer
(Long and Short term)
Including
timelines/timeframes
Patient will regain
mobility at the highest
possible level by
10/5/2022
Patient will Maintain
position of function by
10/5/2022
Patient will be successful
using the incentive
spirometer by 9/31
(V) Scientific Rationales
Best Evidence with
References
Increase blood flow to
muscles and bone to
improve
Muscle tone, preserve
joint mobility, and to
prevent contractures or
atrophy
Isometrics contract
muscles without bending
joints or moving limbs
and help maintain muscle
strength and mass
Increases available
supplemental oxygen for
optimal tissue
oxygenation
(VI) Evaluation of
Patient
Goals/ Outcomes
Patient able to ambulate
with minimal assistance
No signs or symptoms of
pneumonia