Del Mar College

Nurse Education Dept.

Week # ____________

Student: ___________________________________________
Date: ___________________________________

Level 1 Nursing - Adult Assessment Form

Phase I: Preinteraction
Patient Initials: ____ Date of Admission: ________ DOB: ________ Age & Gender____ /____ Ht. & Wt. ____/____
Religion: ______________ Culture/Ethnicity: _______________ Occupation: ______________________________
Level of Education: ___________________ Primary Language: _______________ Code Status: ________________
Chief Complaint: _______________________________________________________________________________
Primary Medical Diagnosis: _______________________________________________________________________
Secondary Medical Diagnosis: _____________________________________________________________________
Current Treatments: _____________________________________________________________________________
Past Medical History (pre-existing): ________________________________________________________________
______________________________________________________________________________________________
Surgeries Present: _______________________________________________________________________________
Surgeries Past: _________________________________________________________________________________
______________________________________________________________________________________________
Allergies: _________________________ Exercise: _____________________ ADLs: ________________________
Home Medications: _____________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
OTC Meds/Herbal: ______________________________________________________________________________
Disabilities: ___________________________________________________________________________________
___________________________________________________

Vitals Signs
Day 1:

Time________ B/P________ T________ Apical ________ R________ P________ O2________

Day 2:
Time________ B/P________ T________ Apical ________ R________ P________ O2________
Variances:

Phase II: Initial Interview

LOC

Oriented to
Other: _________________________________________________________________

staying focused, forgetfulness, headaches, or history of head trauma? __________________________________

___________________________________________________________________________________________
ces Describe: ________________________________________________________________
Impairment Describe: ____________________________________________________________
es Type: ___________________________________________________________________________
Do you have numbness, tingling, or muscle weakness? Describe: _________________________
___________________________________________________________________________________________
Describe ________________________________________________________
1. Visual Impairment:
2. Hearing Impairment:
___________
-term Impaired
Describe: __________________________________________
Variances:__________________________________________________________________________________

Throughout your assessment, rate pain on a scale of 0-10, with 0 being no pain, and 10 being the worst pain
imaginable. Describe quality, location, and frequency. Describe subjective and objective data as appropriate.

Phase III: Focused Interview

Circulation

Heart Sounds:
Site
Rate

Rhythm*

Quality

Radial

Site

Rate

Brachial

Posterior
Tibial
Pedal

Apical

Others

Rhythm*

Quality

Quality Scale:
0 Absent
1+ Thready/Weak
2+ Normal
3+ Increased
4+ Bounding

R = Regular
I = Irregular

-pitting Edema Scale: _________

_____________
__________________________________________________________________________________________
Variances:_________________________________________________________________________________
Oxygenation

Rate: _____per min

Quality:

Depth:
___________________________

-productive

Describe: ________________________________
Delivery Device
2

_______________
Variances: _________________________________________________________________________________
Musculoskeletal

_______
6. Activities of Daily Living: (Fill in the blanks with I = Independent A =Assist D = Dependent)
____Feeding _____Bathing _____Grooming ____Toileting ____Dressing
Muscle Strength: Strong Weak None
Muscle mass/tone: _______________________________
Upper Extremity Grips: _____ Right _____ Left Lower Extremity Pushes:_____ Right _____ Left
ROM
Balance Problems

Variances: _______________________________________________________________________________

General Health

Describe: _______________________________________________________
4
________
5. Have you had head or neck pain, neck masses, or swollen nodes: ____________________________________
Lymph Node __________________
Variances: _________________________________________________________________________________
___________________________________________________________________________________________
GU - Genitourinary & Elimination

Description per: ____Nurse _____Patient

2.

________________________
Describe: _______________________________________________________

4.
6. Last 24 hr. fluid intake __________ ml
Bladder:

_____________________
7. Last 24 hr. urinary output __________ml

________________________
Sexual-Reproductive Pattern
8
Males:
Females:
Variances: _________________________________________________________________________________
__________________________________________________________________________________________
GI Gastrointestinal & Elimination

Description of bowel movement per _____Nurse _____Patient

Food Allergies: ____________________
2. Nutritional Supplements: Type & Frequency ____________________________________________________
Fingerstick Frequency: ________________________

6. IBW: _______________ BMI: ______________

7. Recent changes in Ap
Describe: _________________________________________________________________________________
8. Recent Weight los
________ over how long ________________________
9
Date of Last BM:_____________
Patient regular bowel pattern___________________
Bowels:
______
Medications/practices that affect bowel elimination: ________________________________________________
Variances: __________________________________________________________________________________
___________________________________________________________________________________________

Nutritional-Metabolic: SKIN

1. Color:
2. Turgor:

Temperature
Moisture

3. Assess:
Location: _______________________ Size in cm: _________ Edges
Location: _______________________ Size in cm: _________ Edges

-Approximated
-Approximated
strips

_________________________________________________________________________________________
8. Braden Score___________ Treatment/measures to be implemented: ________________________________
_________________________________________________________________________________________
9. Do you have frequent skin infections/explain? ___________________________________________________
Variances: _________________________________________________________________________________
__________________________________________________________________________________________
Psychosocial

Coping/Stress Pattern
What people give you the most support? _________________________________________________________
How do you deal with stress & resolve problems? _________________________________________________
Role/Relationship Pattern
Do you have regular social interaction? ________________________________________________________
Can you identify your roles and relationships? ____________________________________________________

Value/Belief Pattern
What activities give you strength, comfort, support? ______________________________________________
What influences your perception of health? _____________________________________________________
What activities help you maintain or improve your health? __________________________________________
What do you know about your current medical condition? __________________________________________
Do you use any religious practices to help you cope? ______________________________________________

Self-Perception/Self-Concept Pattern
How do you see yourself? ____________________________________________________________________

Sleep/Rest Pattern
1. How many hours of sleep do you need to feel rested? __________ Current hours of sleep: __________
2. How do you promote sleep or get back to sleep? ____________________________________________
3. Do you take medications that promote sleep? ______________________________________________
4. Do you have a bedtime routine? ________________________________________________________
Activity/Exercise? _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Erik Ericksons 8 Stages of Psychosocial Development

Check behaviors observed on both positive and negative indicator columns. Evaluate behaviors in relation to the clients situation, age
and illness. Determine the clients strengths and areas that need support from evaluation of behaviors seen during contact with the
client. Make an assessment with rationale statement that identifies the level of development your client is functioning in.
STAGE

AGE

INFANCY

Birth- 18
months

TASK

Trust vs Mistrust

HOPE/CONFIDENCE
Trusts others
Positive in Beliefs
WILL
Capable of free choice
Self control
Positive self-image

EARLY
CHILDHOOD

18 m- 3 years

Autonomy vs
Doubt & shame

LATE CHILDHOOD

3-5 years

Initiative vs Guilt

SCHOOL AGE

ADOLESCENCE

6-12 years

12-20 years

CLIENT BEHAVIOR
Positive Indicators

Industry vs
Inferiority

Identity vs
Role Confusion

PURPOSE/COURAGE
Believes that can influence
environment
COMPETENT
Dexterous ability to:
Create
Develop
Manipulate
FIDELITY
Can sustain loyalty in difference
in values
Demonstrates coherent sense of
self

YOUNG ADULT

18-25 years

Intimacy vs
Isolation

LOVE
Mutual intimate relationship
with another

CLIENT BEHAVIOR
Negative Indicators
Mistrusts
Withdraws
Estranged

Compulsive self-restraint or
compliance

Lacks self confidence

Loss of hope
Sense of well-being only
mediocre

Confusion
Indecisiveness
Unable to find occupational
identity

Impersonal with relationship

Commitment to work
relationships

ADULTHOOD

MATURITY

25-65 years

65 years
to death

Generativity vs
Stagnation

Integrity vs
Despair

CARE
Widened concerns for what life has
generated through:
Creativity
Production
Love
WISDOM
Ability to see life as successfully
achieved:
Detached concern with life:
Accepts worth of own life
Accepts possibility of own death

Self-indulgent
Self-Concern
Lack of interest or
commitments

Sense of loss
Contempt for others

Statement of client level of functioning assessment with rationale: __________________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Clinical Prep / Patho

Medical Diagnosis: _____________________________________________
Textbook Disease Process
Signs/Symptoms per Textbook

My Patient Findings
Patient Signs/Symptoms with this Condition

Textbook Expected Medications Ordered for this Condition

My Patient Medications Ordered specific for this Condition

Textbook Expected Diagnostics Ordered for this Condition

My Patient Diagnostics Ordered specific for this Condition

Textbook Nursing Interventions for This Conditions

--Interventions Specific for this Condition should be similar if

not the same,

My PRIMARY Nursing NANDA for this condition:

Problem
RT
AEB

Does your patients care as the Dr. has ordered compare or come close to Text Book plan? Yes or No, explain:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Diagnostic Tests / LABS

Test Component

1. Chemistry (BMP):
Normal
Admission
Values
Results

Recent
Results

2. Hematology:
Normal
Value

Recent
Results

Is this test done Daily? Yes

No
Indications/Disease/Conditions

Na+
K+
ClCO2
BUN
Creatinine
GFR
Glucose
Ca

Test Component
Auto / Manual
WBC
RBC
Hgb
Hct
MCV
RDW
Platelets

Is there a Manual Difference?

Test Component

3. Urinalysis:
Normal
Value

Admission
Results

Yes

Is this test done Daily? Yes

No
Indications/Disease/Conditions

No (circle one)

Admission
Results

Which components?

Recent
Results

Indications/Disease/Conditions

Recent
Results

Indication/Diseases/Conditions

Appearance
Color
Spec. Gravity
Bacteria
Protein
WBC
RBC
Glucose
4. Liver Function
Test Component
Normal
Admission
Value
Results
Albumin
Prealbumin
Bilirubin, total
Bilirubin, direct
Bilirubin, indirect
AST / SGOT
ALT / SGPT
Protein, total

Diagnostic Tests / LABS

5. Coagulation Studies
Is this test done Daily? Yes No
Test Component
Normal
Admission
Recent
Indications/Diseases/Conditions
Value
Results
Results
Platelets
PT
INR
PTT
Yes No (circle one) Which?
Does this patient take Coumadin, Heparin, or Lovenox?
6. Arterial Blood Gases (ABGs)
Test Component
Normal
Admission
Recent
Value
Results
Results
PH
PCO2
PO2
HCO3
O2 sat
7. Cardiac Enzymes
Test Component
Normal
Admission
Value
Results
AST/SGOT
CPK
CPK-MB
LDH
Myoglobin
Troponin I
Troponin T
CRP

Is this test done Daily? Yes No

Indications/Diseases/Conditions

Recent
Values

Indications/Diseases/Conditions

8. Any Other Lab Study

Test Component
Normal
Admission
Values
Results

Recent
Results

Indications/Disease/Conditions

9. Radiology
Exam

Results

Date

Reason Ordered

10. Finger Stick(s) Glucose (FSBS) Checks are they ordered: Yes No

Normal Range:
Drs Order

Clinical Day 1
Coverage given

0700

1130

1630 2100

Other

Medication & Research Sheet / MARS

Lab Indications What lab values does the medication INC. or DEC.?
Medication Drug +
dosage, route, & frequency

Functional
Classification

Action

Why is your client on

this drug?

Lab Indications
(Cite data that the drug is
therapeutic for your client)

Nursing Implications
(Monitor, Assess, when to Hold)

CARE PLAN #1 NANDA

SMART = Specific, Measurable, Attainable, Realistic and Timed
Data Collection
SUBJECTIVE
DATA

Nursing Diagnosis
(3 part NANDA)

ACT = Assess, Care, Teach

Interventions & Provide
Rationales for each intervention

P=

GOAL Statement

Et. =

OUTCOME #1

A=

C=
OBJECTIVE DATA
T=

Evaluation of Patient Response to

Nursing Interventions
Was Your Overall Goal Met?
YES or NO
Explain:

Did pt. achieve Outcome #1?

YES or NO
Explain:

S /S =

OUTCOME #2

A=

C=

T=

Did pt. achieve Outcome #2?

YES or NO
Explain:

Care Plan #1: EVALUATION & MODIFICATION

Evaluation of
Interventions /
Outcomes

OC #1

New Data:
For changes to Nrs Dx or
reasons to keep the current
Nrs Dx

SUBJECTIVE DATA

Modifications: New Nrs Dx

Change to another problem
based on new data or if keeping
current Dx

New Goals / Outcomes

Interventions: Revised / New

P=

E=

OC #1

A=

C=

OC #2

T=

OBJECTIVE DATA

S /S =

OC #2

A=

C=

Outcomes - Circle One:

Met
Not Met
Partially Met

T=

CARE PLAN #2 NANDA

SMART = Specific, Measurable, Attainable, Realistic and Timed
Data Collection
SUBJECTIVE
DATA

Nursing Diagnosis
(3 part NANDA)

ACT = Assess, Care, Teach

Interventions & Provide
Rationales for each intervention

P=

GOAL Statement

Et. =

OUTCOME #1

A=

Evaluation of Patient Response to

Nursing Interventions
Was Your Overall Goal Met?
YES or NO
Explain:

Did pt. achieve Outcome #1?

YES or NO
Explain:

C=
OBJECTIVE DATA
T=

S /S =

OUTCOME #2

A=

C=

T=

Did pt. achieve Outcome #2?

YES or NO
Explain:

Care Plan #2: EVALUATION & MODIFICATION

Evaluation of
Interventions /
Outcomes

OC #1

New Data:
For any changes to Nrs Dx or
reasons to keep the current
Nrs Dx

Modifications: New Nrs Dx

Change to another problem
based on new data or if keeping
current Dx

SUBJECTIVE DATA

P=

E=

New Goals / Outcomes

OC #1

Interventions: Revised / New

A=

C=

OC #2

T=

OBJECTIVE DATA

S /S =

OC #2

A=

C=

Outcomes - Circle One:

Met
Not Met
Partially Met

T=

APIE Chart
A = Assessment - You should have an initial assessment on your patient and an assessment per hospital
protocol every 2-8 hours. As changes occur, you may add problems to your list or delete them from the
problem list.
P = Problem + Etiology + Signs and Symptoms (Nursing diagnosis that gives documentation of initial
assessment of the client in relation to an identified problem. Each problem must be numbered and opened
only one time. Interventions and Evaluations (I and E) that follow must have that same problem number.)
I = Intervention - Document nursing orders or what nurse does for client.
E = Evaluation - Document client response to interventions. Includes reevaluation of signs/symptoms
listed in the problem section.
DATE:_________________________________
Physical
Problem #

NANDA 3 part statement

Psychosocial
Problem #

NANDA 3 part statement

Time APIE Progress Note

**Continue on additional paper as needed.

Del Mar College

Weekly Self Evaluation
Write a self-evaluation each clinical week. Give specific examples of how each of the criteria was met.
Caring establish trusting, interpersonal relationships with adult clients, incorporating caring behaviors. Include the
following:
How did you develop rapport and awareness of cultural respect, demonstrate an understanding of the advocacy process,
and develop patience and compassion?

Communication utilize basic communication skills when caring for adult clients. Include the following:
How did you apply general principles of therapeutic communication, utilize professional and personal qualities to enhance
communication, document in written and electronic records?

Competency provide safe, evidence-based nursing care to adult clients. Include the following:
How did you implement safe fundamental nursing care for adult clients, recognize responsibility for quality of nursing care,
and identify the value of life-long learning and recognize the need for self-assessment to improve your own nursing
practice?

Clinical Decision-Making begin using critical thinking skills and nursing process while providing basic nursing care to
adult clients. Include the following:
How did you distinguish normal vs. abnormal function and factors that inhibit normal function, demonstrate technological
skills and focused nursing assessment skills, and administer medications using the five rights?

Comments:

Student Name__________________________
Date_________________________________

Careplan Grading Rubric

Areas Evaluated

Points
Possible
Week 1-4

Points
Possible
Week5-9

1. Adult Assessment
2. Pathology Sheet

15
5

10
5

3. Medications

15

10

4. Labs/Diagnostics

15

10

1. Diagnosis
2. Goal

15
10

10
10

3. Outcomes

10

10

4. Nursing
Interventions with
Rationales
5. Evaluations

10

10

10

6. Modifications

10

ASSESSMENT

NURSING CARE
PLAN

DOCUMENTATION
1. Correct charting
format (APIE, AIR,
DAR) Correct use of
medical terms,
spelling, grammar,
punctuation
TOTAL

100

Points
Earned

Comments