Brief RAM Assessment/Data Collection Sheet

(To accompany Care Plan Design Form)

Student Name Clinical Site Date

Client’s Initial Code: Code Status: Vital Signs: Time

Primary Diagnosis
PMH PSH T Route
AP Radial
R O2 Sat

Pain Assessment:

Admission Date: Ht. Allergies

Wt.
RAM Behaviors—Physiologic
Oxygenation (Vital signs above) Protection
O2 L/M via Skin Status: Wounds:
Lung Assessment: Color Drains:
Temperature Last Dressing Change:
Cardiovascular Assessment: Turgor Type of Dressing

Nutrition Elimination
Diet: TF Bolus/Gravity/Pump Bowel N/V/D Urine
Type of feeding:  Incontinent  Incontinent
Appetite:  Ostomy (type) Last Void:
Rate Urine Output:(Description):
Fluid and Electrolytes Last BM:
Description:
IV(s): Site:
Abdominal Assessment: Bladder distention?
Gauge
Rate  Catheter
Assessment: Type Size
HL/CVP/Other Access Date inserted:
Rest and Activity Endocrine Neurologic Function & Senses (Pain assessment above)
Activity: OOB/ BRP/Bedrest Glucometer Readings: Overall appearance: Review of cranial nerves:
Activity tolerance:
LOC:
ROM: Assessments of Endocrine Senses:
Gait: Function: Mood & Affect
Transfers:
Sleep: Paralysis/Paresis MMSE Score
Glasgow Coma Score

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This is intended as a guide and is subject to change as needed
 Psychosocial
Self Concept Role Function Interdependence
Body Image/Religion /Erickson’s Roles/Role Transition Support Systems
Stage

Stimuli
Focal Conceptual Residual

Medications
Medication Dose Frequency Route Nursing Considerations

Laboratory and Diagnostic Studies

(CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.)

Teaching and Discharge Needs Related to Behaviors and Stimuli

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This is intended as a guide and is subject to change as needed
 Indicate the Mode
Student Name: Patient Initials CODE __Physiologic Mode
__Self Concept Mode
Instructor: Date __Role Function Mode
__Interdependence
Nursing Care Design Sheet
Behaviors Stimuli Nursing Diagnoses Nursing Interventions Evaluation of
Non-Observable Observable Focal, Contextual, NANDA and Rationales (Impact) Patient
(Subjective) (Objective) Residual List 3 in priority order. (Best Evidence-Based Goals/Outcomes
Check the one you address. Rationales with references)

Patient Care
Goals/Outcomes
Short and Long Term
(Including timeframes)

3
This is intended as a guide and is subject to change as needed