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Criteria

4 points

3 points

2 points

0 points

Total Points

Part I: Physical Assessment

All components of the physical assessment are present.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the assessment areas are lacking information.

Assessment information not provided

Part II: History & Physical

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part III: Medications

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part IV:

Diagnostic Studies & Interpretation/Assessment Explanation

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part V: Clinical Judgement Measurement Model Table

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Total points

/20

GENERAL SURVEY

Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic

Height___________ Weight____________ Well-groomed Poorly Groomed

Facial Expression: Content Happy Anxious Sad Angry Flat

NEUROLOGICAL

(LOC) Level of

Consciousness

Alert Awake Lethargic Obtunded Stupor Comatose Confused

Oriented x 4:

If not alert X 4, circle what they are alert to: Person Place Time Situation

Eyes

Unaided sight Glasses Contact lens Blind

Pupils

Equal Round Reactive to light Accommodates List abnormal findings:________________________________________

Pupil reaction: Brisk Sluggish Nonreactive to light

Pupil size: before light ______mm after light ______mm

Ears

Unaided hearing Hard of hearing Deaf Hearing aid Implant

Extremity Strength

Hand grips +1 +2 +3 +4 +5 equal unequal

Foot pushes +1 +2 +3 +4 +5 equal unequal

Pain

Location:

Onset (when did it start):

Provokes (makes it worse):

Palliates (makes it better):

Quality (description):

Radiate: location:

Severity: ___/10

Time: Constant Intermittent

CARDIOVASCULAR

Skin / Mucous Membranes

Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic

Radial and Pedal Pulses

Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent

Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent

Apical Radial Pulses

(2 assessed simultaneously) Equal Pulse Deficit

Capillary Refill

Normal (<3 Sec) ______sec Location:________________

Edema

Absent Present: location +1 +2 +3 +4 Non-Pitting

Heart Rhythm/

Sounds – S1S2

Heart Rhythm: Regular Irregular

Heart Sounds: S1/S2 Murmur Extra Sounds

Sound: Strong Distant

IV

None

Solution_______________ Rate ____ml/hr

Site location (be specific) ______________________________________

Site appearance: WNL Edema Erythema Tender Pallor

Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________

RESPIRATORY

Respirations

Pattern: Regular Irregular

Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction

Chest Expansion: Symmetrical Asymmetrical

Lung Sounds

Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______

Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______

Cough

None Non-productive Productive Sputum: amount color

Oxygen

Room air O2 at_____L/min

Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask

Respiratory Treatments

Incentive Spirometer (IS): ml______ # of times______

Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________

GASTROINTESTINAL

Oral

Mouth: Teeth Dentures Caries

Swallowing: Gag reflex Dysphagia

Mucous Membranes: intact moist dry pale pink

Abdomen:

Contour: Soft Round Flat Scaphoid Obese

Palpation: Firm Hard Tender Non-Tender Location:

Distention: Nondistended Distended

Bowel Sounds

RLQ Normoactive Hypoactive Hyperactive Absent

RUQ Normoactive Hypoactive Hyperactive Absent

LUQ Normoactive Hypoactive Hyperactive Absent

LLQ Normoactive Hypoactive Hyperactive Absent

NG/ GT/ JT

None

Type of tube _____ patent non-patent

Purpose: Suction Feeding Medication Administration

Type of food: _________ Fluid Flush__________mL

Bowel Movement

Continent Incontinent

Last BM__________ Color Consistency

Ostomy: yes no

Nutrition

Self-feed Needs assistance

Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________

Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed

Tube Feed: Yes or No

GENITOURINARY

Urine

Continent Incontinent

Urgency Hesitancy Frequency Burning Nocturia

Catheter type _______________ None

Color_________________ Clear Cloudy Sediment Burning Frequency

Intake and Output

PO/Oral/Tube Feed intake____________ mL

IV intake____________ mL

Urine output_________ mL

Other output_________ mL

Fluid restriction ___________mL/day

MUSCULOSKELETAL

ROM

Active ROM: Completed____________ Passive ROM: Completed____________

Mobility

Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair

Walks: distance frequency tolerance PT OT

Other Musculoskeletal

Cast: Location:

Brace: Type: Location:

Amputation: Location:

Risk for Falls

Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board

INTEGUMENTARY

Appearance

Color: Normal for Ethnicity Pallor Rash Bruise Lesions

Intact

OR

Non-Intact: Location of Non-Intact Areas_____________________________________________________

New Scars: Location _________________________

Dressing change: (describe: location, steps, drainage, wound)

Temperature and Moisture

Temperature: Warm Hot Cool Cold

Moisture: Dry Moist

Incisions/Wound

None

Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips

Dressing: Dry/intact Non-intact Change: yes no

Drainage: Color Amount___________ Odor_________

Wounds

Location: Wound appearance Tunneling Eschar Slough

Location: Wound appearance Tunneling Eschar Slough

Location: Wound appearance Tunneling Eschar Slough

PSYCHOSOCIAL

Behavior

Cooperative Uncooperative

Pleasant Withdrawn Combative Other_______________

Language spoken

English = speaks and understands other_________________ Interpreter

Part II: History and Physical

Nursing Care Plan:

Date:

A. Client identifiers:

Physician (s):

Age: Gender: Ht: Wt. Code Status:

Isolation Status:

Health States

Date of admission:

Activity level: Diet:

Fall risk:

Client’s chief complaint:

Client’s past medical and surgical history

Allergies:

Mobility needs: (Independent, partially-dependent, full-assist)

Interdisciplinary Consults (PT/OT/RT/ST/other):

Referrals to Specialists (pulmonary, cardiac, neuro, etc.)

Socio-cultural Orientation

Cultural and Ethnic Background

Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, and

financial abuse)

Barriers to independent living

Part III. Medications

List medications, dosages, classifications, and the rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication. A maximum of twelve (12) medications focus on the medication corresponding to the patient’s primary and chronic health conditions.

ALLERGIES:

Medication, Classification, Mechanism of Action

Dosage/Route

Contraindications, Adverse Reactions/Side Effects, Risk Factors,

Client Education and Nursing Implications

Why is this client getting this medication?

PART IV: Diagnostic studies and Interpretation (Maximum of 5 lab values)

Labs

Normal Values

Results

What do these results indicate?

Identify 2 interventions based on the laboratory findings (examples: Medications, procedures, positioning)

Assessment Explanation

Identify three (3) nursing interventions based on the Physical Assessment findings

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State the educational needs of this client.

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Recognize Cues

Identify five (5) abnormal Signs, symptoms, risk factors, labs, and health history, clinical manifestations.

Prioritize

Using the Recognize Cues column to prioritize the chief complaints

Generate Solutions

List three (3) nursing interventions needed for this client. Use the three (3) interventions identified above.

Evaluate Outcomes

How would you determine the effectiveness of your nursing interventions?

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