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On-Going Assessment in Clinical Setting
On-Going Assessment in Clinical Setting
1281 Tropical Ave. corner Luxembourg St., BF International, Las Piñas City
Tel. No.: 825-6374, 820-8702 to 03; Fax No.: 820-8715
VASCULAR ACCESS
BR IV #1
Dangle
Chair IV #2
Amb
Type of Activity
BRP
ACTIVITY
BSC IV #3
Refused 4. No limitations
Non-distended Distended
Void ad lib Bowel Sounds 1. Verypoor
Normal Hypoactive
ONELIMINAT
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
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