Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
1
Date: ____________
Staff RN/Patient Care RN to fill out pgs. 1-16
Patient Data:
RM: _______ Age: ______ Gender: ________
Primary Care Physicians: __________________________________
Consulting Physicians: _________________________________________________
CODE STATUS: _________________ Living Will/Advance Directive: ______________
Allergies: _______________________________ Reaction(s): _______________________
Primary Language: __________________
Medical Diagnosis: _________________________________________
Medical History: ___________________________________________
_________________________________________________________
Surgical Diagnosis: _________________________________________
Surgical History: __________________________________________
General Health Status:
Generally well ____ Fair _____ Poor _____ Very Poor ____
Recent/Current Viral/Bacterial Infections: Yes ____ No _____
If yes, list infection(s) experienced by pt.:_________________________
History of substance use: Alcohol ______ Tobacco _____packs/year
Recent/Current Accidents or falls: Occurrences______ Dates: ______
(If applicable) Injuries sustained ______________________________
o Altered Health Maintenance
o Effective management of
therapeutic regime: individual
o Ineffective management of
therapeutic regime: individuals
o Ineffective management of
therapeutic regime: Families
o Noncompliance
o Health-seeking behaviors
o Latex allergy
o Risk for latex allergy
o Risk for infection
o Risk for injury
o Risk for poisoning
o Risk for suffocation
Critical Thinking Skill
o Delayed
recovery
Using the information collected in this section identify any potential problems that
could surgical
be
o Risk for peri-operative
anticipated for this client.
positioning injury
How (or what) would you assess your client to determine if these problems are occurring?
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Page 1 of 19
2
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Date: ____________
Sensory:
Hearing: ___________ hearing aids: R____ L_____
Vision: Adequate ______ Poor ______ Blind _______
Corrective Lenses: Yes ______ No ______
Type ______________________________
o
Pain
o
Chronic pain
o
Short-term Memory: Intact ________
Long-term Memory: Intact ________Periods of Confusion _______
Severely Impaired _______
Pain: Location _________ Pain Scale ____ (1-10) Duration _______
Characteristics: Sharp _____ Dull _____ Aching ______ ______
Throbbing________
Contributing Factors; ___________________________________
Management/Relief Measures: Pharmacological _____________
Non-Pharmacological _____________________________
Neurological Assessment:
Pupils' _______________ Size: Left _____ Right ______
Hand grasps: ________Right __________Left __________
Orientation: Alert _________
Oriented x ______ (_________,_________,________)
Speech: Clear ________
Garbled _________ Aphasia __________
Mood: Calm/Pleasant ________ Angry ______ Anxious _______
Laboratory Data:
o
o
o
Sensory perceptual
alteration (specify
Decreased intracranial
adaptive capacity
Unilateral neglect
Knowledge deficit
(specify)
o
Impaired memory
o
Altered thought process
o
Acute confusion
o
Chronic confusion
o
Decisional conflict
Pt. Results
Facility Normal Values
Significance
Dilantin Level
_________
Tegretol Level
_________
Valporic Acid Level _________
____________________
____________________
____________________
________________________
________________________
________________________
Other _________________ _____________
___________________________
________________________________
(If applicable)
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
Document1
Page 2 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
3
Date: ____________
Nutrition:
General Appearance (hygiene, grooming): _____________________
Skin Color: Pink _______ Pale ________ Ashen ______
Gray __________ Brown __________
Temperature: Warm ________ Cool ____________
Texture: Dry ______ Moist ______ Clammy ______Diaphoretic __________
Turgor: Elastic_________ Non-elastic __________ Poor ________
Rashes/Lesions: Size ___________ Color ____________________
Location(s): _____________________________________________
Petechiae: Location(s)______________________________________
Ecchymoses: Location(s)___________________
Lacerations/Abrasions: ______________________________________
Mucous Membranes: Color_____ Moistness ______ Lesions ________
Gums: Color _________ Moist/Dry _______ Sore areas _____________
Lips: Dry/Chapped ________ Pink/Moist _______
Breath Odor: Fruity ______ Foul ______ No odor ________
Drains: Drainage Color _________ Drainage Amt. _________ ml
Type of Drain: JP ____ Hemo-vac ______ Penrose ________
Surgical Incision: Location ____________________________,
Number of Staples/Sutures ________
Incision Appearance: Intact_____ Edges Approximated: Yes ___ No ____
Surrounding Tissue: Red/Inflammed ___ Slightly Red ___ Pink _____
Drainage: Color: Sero______ Sero-Sanquinous _______
Bright Red Blood ________
Amt: Copious _____ Moderate _______ Scant ______
Odor: Yes ____ No _____
o Altered Nutrition: risk
for more than body
requirements
o Altered nutrition: more
than body requirements
o Altered nutrition: less
than body requirements
o Risk for aspiration
o Impaired swallowing
o Nausea
o Altered oral mucous
membrane
o Altered dentition
o Risk for fluid volume
imbalance
o Risk for fluid volume
deficit
o Fluid volume deficit
o Fluid volume excess
o Risk for impaired skin
integrity
IVNutrition:
Angio Catheter size: #_______GA,
Location:______________, Anterior______ Posterior _________
RFA = right forearm,
RAC = right antecubital
LFA = left forearm
LAC = left antecubital
RTH= right top hand
RW = right wrist
LTH = left top hand
LW = left wrist
Appearance of Site: Clear_______ Redness _____ Edema_______
o Impaired skin integrity
o Impaired tissue integrity
(specify type)
o Risk for altered body
temperature
o Ineffective
thermoregulation
o Hyperthermia
o Hypothermia
o Adult failure to thrive
Fluid:__________________
Added Medications (to primary infusion only)____________________________o Risk for altered growth
Rate of Infusion (ml/hr): ____________
Drops per minute:________, _________ per pump
If applicable, Type of Central Line: PICC _____ Midline _______,
Porta-cath ________ RIJ _______ LIJ______
RFem_______ LFem______
Date of last Dressing Change: ____________
Frequency:_________________
T.P.N. _______, Fat Imulsions ________%
Rate of Infusion: ____________
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Page 3 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
:
Laboratory Data
Normal Facility
Values
Pt. Results
4
Date: ____________
Is result normal
or abnormal?
Significance
to the patient?
Glucose
Protein
Albumin
Globulin
Albumin/globulin
ratio
Total bilirubin
BUN
Creatinine
AST/SGOT
ALP
ALT/SGPT
Sodium
Potassium
Chloride
CO2
Magnesium
Calcium
Diet ______________________________ Height _______ Weight _______
Dietary/SwallowingPrecautions______________________________________________
Average past 72 hr. Food intake ______ % Average past 72 hr. Fluid Intake ______ml
Appetite: Good ___________Adequate ______ Poor ______
Oral Supplements __________________________
Type and size of Feeding tube in place: Dobhoff NGT______ GT __________
Placement verified ________ Residual ________ ml
Tube Feeding: Type _____________ Rate of Infusion _______________
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Page 4 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
5
Date: ____________
H2O Flushes: Amount _________ml Frequency _______________
Dentures: None ______
Upper _______
Lower ________
Do they wear them? Always ______ Never _______ for Meals _______
BRADEN RISK ASSESSMENT SCALE
Sensory/Perception
Moisture
Activity
Completely limited
Completely
Bedfast = 1
=1
Moist = 1
Very Limited =2
Very Moist = 2
Chair fast =2
Slightly Limited =3
Occasionally
Walks
Moist =3
Occasionally =3
No Impairment Rarely Moist = 4
Walks
=4
Frequently
=4
Score: _______ +
Score:______ + Score:______ +
Mobility
Nutrition
Friction/Shear
Completely
Very Poor = 1
Problem = 1
Immobile =1
Very Limited = 2
Probably
Potential Problem
Inadequate = 2
=2
Slightly Limited =3
Adequate =3
No Apparent
Problem =3
No Limitations = 4
Excellent = 4
Score: _____ +
Score: ______ +
Score:______ + Total: _________
Score Key
12 or less:
High Risk
13 or 14:
Moderate Risk
15 or 16:
Low Risk
17 or above:
No Risk
Wounds: Stage(s)_____ Measurements __________ cm Depth _______
Odor/Drainage ___________ Location/Description ____________________________
Current TX: ____________________________________________________________
Pressure relief devices: ___________________________________________________
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 5 of 19
6
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Date: ____________
Elimination:
Bowel Assessment: Continent ____ Incontinent __________
Size: Sm.___ Med. ____ Lg._____
Color: _________________
Consistency: Hard/Formed ____ Soft/Formed ____
Loose/Watery ______
History/Current use of laxatives and stool softeners:
Yes ___ No ___
Date of last bowel movement ____/____/_____
Frequency: __________________
Abdomen: Soft ___ Flat ____ Hard ____ Distended ______
Obese _______ Tenderness _____
Bowel Sounds:
Present RUQ ____ RLQ _____ LUQ _____ LLQ ______
Hyperactive_____ Hypoactive ______ Sluggish _______
Ostomy: Type: Colostomy_____, Ileostomy_____
Appearance of Peristoma and Stoma:
Moist _____ Reddish-pink______ Other: ______________
Hemocult findings:(If applicable) ___________________________
________________________________________________________
Urinary Assessment: Continent __________ Incontinent _________
F/C: Size Fr. ________ Balloon ________
Bedside Drain _____ Leg Bag _______ BSC_____
Ostomy: Type: Urostomy_______, Nephrostomy______
Appearance of Peristoma and Stoma: Moist_____ Reddish-pink_____
Other: ______________
Urine: Color ______,Clarity______,Consistency ________,
Odor ______, Amount ________ml
Laboratory Data:
pH
Protein
Specific gravity
Leukocyte esterase
Nitrites
Ketones
Urobilinogen
Crystals
Glucose
WBC's
RBC's
Bacteria
Yeast
Blood
Culture & Sensitivity
Document1
Pt. Result
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
Facility Normal Value
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Page 6 of 19
o Constipation
o Risk for Constipation
o Perceived constipation
o Diarrhea
o Bowel incontinence
o Altered urinary elimination
o Functional incontinence
o Reflex incontinence
o Stress incontinence
o Urge incontinence
o Risk for urinary urge
incontinence
o Total incontinence
o Urinary retention
Significance(If applicable)
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
7
Date: ____________
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 7 of 19
8
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Date: ____________
Cardiovascular
o Risk for activity intolerance
Cardiac Assessment:
o Activity intolerance (specify
level)
BP:___/_____
Radial Pulse: Rate ______ bpm Strong_______ Bounding ______
Weak/Thready ________
Apical Heart Rate: Strong/Regular ______ Irregular _____
Reg. /Irreg. _____ Rate: ____bpm
Palpable Peripheral Pulses:
Temporal_____ Carotid_____ Brachial____ Femoral _____
Radial _____ Pedal, R ______ L ______ Posterior/Tib._____
Edema: Generalized _____
Pitting ______ 1+ ___ 2+ ____ 3+ _____ 4+ _____
Locations ___________________________________________
o Fatigue
o Decreased cardiac output
o Altered tissue perfusion Risk
for peripheral vascular
disease
o Impaired home maintenance
management
Laboratory Data:
Pt. Results
Facility Normal Values
Serum Na+
K+
Ca++
Mg++
Cholesterol
Triglycerides
LDL
HDL
Chol/HDL ratio
__________
__________
__________
__________
__________
__________
__________
__________
_________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
___________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
PT
INR
PTT
Fibrinogen
__________
__________
__________
_________
____________________
____________________
____________________
___________________
________________________
________________________
________________________
________________________
#1._________
#2._________
#3._________
_________
_________
_________
_________
_________
_________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
________________________
________________________
________________________
________________________
________________________
________________________
_______________________
________________________
________________________
_________
____________________
________________________
Troponin
Myoglobin
CPK MB
CK
LDH
AST
Digoxin Level
(If applicable)
D-Dimer
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Page 8 of 19
Significance
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
9
Date: ____________
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
Respiratory Assessment:
Breath Sounds:
RUL__________ RLL _________ LUL_________ LLL ___________
o Dysfunctional
ventilatory weaning
(Clear, Wheezing (Inspiratory, Expiratory) Crackles, Rhonchi, Rubs)
response (DVWR)
Respirations: Rate________, Depth/Equal_______
Labored/Non-labored_________
o Inability to sustain
Capillary refill: ___________ Cyanosis present ____________
spontaneous ventilation
Humidified _________ O2 Saturation _______%
Nebulizer Treatment: _______ MDI's ________
o Ineffective airway
clearance
Cough: Non-productive________, Productive_______
Sputum: Color _____ Consistency____ Amount_______ Odor_______
o Ineffective breathing
Tracheostomy: Type & Size: ________________________________
pattern
Oxygen Percentage: ________% Trachea mask in use: Yes ____ No _____
Frequency of Trachea Care: _____________________________
o Impaired gas exchange
Appearance of Trachea Stoma: Moist_______ Pink _______
If applicable, describe stoma drainage: _____________________
Tracheal Secretions: Color_____, Consistency______ Amount_____ Odor______
Oxygen via: NC____lpm, NRB Mask _______% RB Mask ________%
Laboratory Data:
Pt. Results
Facility Normal Value
Significance
RBC
WBC
Platelets
Hgb
Hct
MCV
MCH
MCHC.
RDW
Neutrophils
_________
_________
_________
__________
__________
_________
_________
_________
__________
__________
___________________
___________________
___________________
____________________
____________________
___________________
___________________
___________________
____________________
____________________
________________________
________________________
_______________________
________________________
________________________
________________________
________________________
_______________________
________________________
________________________
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Page 9 of 19
10
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Date: ____________
Lymphocytes
Monocytes
Eosinophils
Basophils
_________
_________
_________
__________
___________________
___________________
___________________
____________________
________________________
________________________
_______________________
________________________
ABG's:
pH
PaCO2
PaO2
HCO3
SaO2
__________
__________
__________
__________
__________
_____________________
_____________________
_____________________
_____________________
_____________________
________________________
________________________
________________________
________________________
________________________
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
Activity:
Gait: Steady/Straight _______ Swaying/Unsteady________
Posture: Straight/Steady _______ Bent/Poor _________
Amputations:_____________ Prosthesis: _______________
Range of Motion: Upper extremities: Active________ Passive________
Lower extremities: Active _______ Passive ________
Contractures ________________________________________________
Splints/Braces used: __________________________________________
Other assistive devices (i.e. cane, walker) _________________________
Prosthetic Devices: ___________________________________________
Traction: Bucks ______ lb. Skeletal _______
Plexi Pulses: Yes ____ No _____, SCD's: Yes _____ No ______
Functional Level Codes:
o Impaired physical mobility
o Impaired bed mobility
o Impaired walking
o Wheelchair mobility
o Impaired transfer ability
o Risk for altered development
o Risk for disuse syndrome
o Bathing/hygiene self-care
deficit
o Dressing/grooming self-care
deficit
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Page 10 of 19
o Feeding self-care deficit
o Toileting self-care deficit
o Diversional activity deficit
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Level 0:
Independent with all ADLs'
Level I:
Requires use of adaptive equipment,
(walker, cane, mech. lifts, crutches)
Level II: Requires assist of one or supervision
Level III: Requires assist of two or more and use of adaptive devices
Level IV: Dependent on staff for all ADLs’
Match the appropriate (functional level code)
that is specific to your patient's needs.
Feeding _______
Toileting _______
Grooming ________
Bathing _________
Dressing _________ Bed Mobility ________
General Mobility __________
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Page 11 of 19
11
Date: ____________
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
12
Date: ____________
Falls Risk Assessment Tool
Overall:
______ History of falls prior to admission
______ Confusion or disorientation
General Data:
_______ Over 60 yrs.
_______ Postoperative/admitted for operation
_______ Smoker
Physical Condition:
_______ Dizzyness/imbalance
_______ Unsteady Gait
_______ Weight bearing joint diseases/other
problems.
_______ Weakness
_______ Paresis
_______ Seizure Disorder
_______ Impairment of Vision
_______ Impairment of Hearing
_______ Diarrhea
_______ Urinary Frequency
Mental Status:
_______ Impaired Memory or judgment
_______ Inability to understand or follow
directions.
Ambulatory Devices:
_______ Cane
_______ Crutches
_______ Walker
_______ Wheelchair
_______ Geriactrics (geri) chair
_______ Braces
Medications:
______ Diuretics or diuretic effects
______ Hypotensive or CNS suppr.
(e.g. narcotic, sedative
psychotropics, hypnotic's
tranquilizer, anti-hypertensive,
antidepressant)
Scoring:
Place a check mark in front of all that apply
to your patient. If a check mark is in front of
One of the overall categories or Four or
more in all the other categories the patient is
at risk for falls.
Risk For Falls: Yes _______ No ________
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 12 of 19
13
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Date: ____________
Sleep-Rest:
Usual bedtime: _______ Usual waking time ______
Number of naps taken ____ how long is each ____________________
Sleep Aids used: Yes ______ No_______ Frequency: ______________
o Sleep pattern
disturbance
o Sleep deprivation
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
Self Awareness:
History of Depression: Yes _____ No ______
Antidepressant/Psychotropics Drug use: Yes _______ No ______
Pts. view of present situation: Positive______ Negative_________
o Fear
o Anxiety
o Death anxiety
o Hopelessness
o Powerlessness
o Risk for loneliness
o Self-esteem disturbance
o Chronic low self-esteem
o Situational low self-esteem
o Body image disturbance
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 13 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
14
Date: ____________
Roles and Relationships:
Marital Status: Married ____ Widowed ____ Single ____ Divorced______
Family Support: Visits Regularly _____ Seldom Visits ____ Never Visits _
Other support system(s): ___________________________________
o Anticipatory grieving
o Dysfunctional grieving
o Chronic sorrow
o Altered role performance
o Social isolation
o Impaired social
interaction
o Relocation stress
Critical Thinking Skill
syndrome
o Altered family processes
o Altered family
Using the information collected in this section identify any potential
problems that could be anticipated for this client.
processes: alcoholism
o Parenteral role conflict
o Caregiver role strain
o Risk for caregiver role
strain
o Impaired verbal
How (or what) would you assess your client to determine if these problems
are occurring?
Reproduction:
Children: Yes _____ No ______
Post Menopausal: Yes _____ No ______
Circumcised: Yes_______ No __________
communication
o Sexual dysfunction
o Altered sexuality patterns
o Rape-trauma syndrome
o Rape trauma syndrome:
compound reaction
o Rape trauma syndrome: silent
Critical Thinking Skill
reaction
Using the information collected in this section identify any potential
problems that could be anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 14 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
Coping-:
Any significant life-style changes in the past year:
Yes_____ No_____
If yes, describe: ___________________________________________
Coping Mechanisms: Pharmacological ___________
Non-Pharmacological ________
15
Date: ____________
o Ineffective individual coping
o Defensive coping
o Ineffective denial
o Impaired adjustment
o Post-trauma syndrome
o Family coping: potential for
growth
o Ineffective family coping
compromised
Critical Thinking Skill
Using the information collected in this section identify any potential
problems that could be anticipated for this client.
o Ineffective family coping:
disabling
How (or what) would you assess your client to determine if these problems are occurring?
Values and -Beliefs:
o Spiritual distress:
Religious/Cultural Observances that may affect care provided
___________________________________________________________
____________________________________________________________
Discharge Plans: Home _______ Assisted Living________
Extended Care Facility ______
distress of the human
spirit
o Risk for spiritual distress
o Potential for enhanced
Spiritual well-being,
Critical Thinking Skill
Using the information collected in this section identify any potential problems that could be
anticipated for this client.
How (or what) would you assess your client to determine if these problems are occurring?
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Page 15 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
16
Date: ____________
List & prioritize (5) NANDA approved nursing diagnoses. A minimum of three nursing
diagnoses must be current/active diagnoses
1.
___________________________________R/T_________________________________
2.
___________________________________R/T_________________________________
3.
___________________________________R/T_________________________________
4.
___________________________________R/T_________________________________
5.
___________________________________R/T_________________________________
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Page 16 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
17
Date: ____________
Treatment RN
Disease Process
Disease: __________________________________________________________
Etiology:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signs/Symptoms:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Diagnosis: (Include assessment data, labs, and diagnostic procedures, that will be anticipated for
this diseases.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Current Treatment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Patient Teaching:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Page 17 of 19
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
18
Date: ____________
Medication RN
Medications
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Classification
Page 18 of 19
Therapeutic Uses for this
client
Side effects/Adverse
Reactions
Nursing considerations
Concorde Career College Associate Degree Nursing Program
Clinical Data Tool for Adult Assessment and Care Planning
Student: _________________________________
Instructor: _______________________________
19
Date: ____________
Medication RN
Medications
Document1
Classification
Page 19 of 19
Therapeutic Uses for this
client
Side effects/Adverse
Reactions
Nursing considerations