Situation
1 Due by Formative Eval/ 1 Due by Summative Eval
Room #: ____________ Age: ______________ Sex: ________________ Code Status: _____________________________________________
Isolation: __Y / N __
Type of Isolation: _______________ Precautions: ___________________________________________________
Chief Hospital Problem and Admitting Diagnosis ________________________________________________________________________
_______________________________________________________________________________________________________________________
Clinical Manifestations on Admission ___________________________________________________________________________________
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Labs and/or Diagnostic Testing Pertinent to Patient Care_________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Background
Past Medical History ___________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Past Surgical History ___________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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Assessment
Neurological
Mental Status
Pupils
Hearing
Sight
Speech
Behavior
Special Considerations
Cardiovascular
Apical Sounds
Quality
Rate
Special considerations
Peripheral Vascular
Radial pulse
Pedal pulse
Capillary refill
Edema
Sensation
Special Considerations
Respiratory
Lung sounds
Pattern
Cough
Secretions
Supplemental O2 rate
Special Considerations
Pain
Location
Duration
Quantity
Quality
Special Considerations
BP: ________ T: _________ P: _________ R: __________ Pain: ___________ PaO2: __________
GenitoUrinary
Voiding
Catheter
Color/Character
Burning /Frequency/Urgency
Special Considerations
GastroIntestinal
Appetite
Nausea/Vomiting
Abdomen
Bowel Sounds
Continence
LBM
Color/Consistency
Mouth
Special Considerations
Musculoskeletal
ROM
Strength
Balance/Gait
Muscle tone
Assistive Devices / Level of Mobility
Special considerations
Integumentary
Turgor
Temp
Color
Moisture
Integrity
Special Considerations
Intravenous
Type
Site
Solution/Rate
Recommendation
Which assessment findings (problems) are you most concerned about right now?
What other members of the healthcare team need to be aware of this problem?
What are priority nursing interventions relate to this problem?
Will the identified problems continue to be a problem when the patient is discharged?
How will current hospitalization impact the “family”?
How will future discharge impact the “family”?
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