Admit Date: Age: Gender: Allergies: Admit Dx: Code Status:…
Question Admit Date: Age: Gender: Allergies: Admit Dx: Code Status:… Admit Date: Age: Gender: Allergies: Admit Dx: Code Status: Activity: Diet: Vital Signs 0800 1200 1600 T HR RR BP O2 In the event an assessment area below is not appropriate simply put NA in the box Neuro: A & O x ________ / Confused: _________________________ PERRLA / Cooperative / Clear speech / Other: ___________________________________________ Activity: Up ad lib / 1 or 2 person assist / Bed rest / BSC / Walker / Cane / Bed Alarm / Fall Risk / Neuro ✓ Cardiac: Pink / Pale / Warm / Cool / Dry / Diaphoretic / Other_____________ Cap Refill time: ________ S1 / S2 / S3 / S4 / Tele / Rhythm: ________________ Auscultation: Reg / Irreg: Murmur: ___________________ Edema: None / Gen / R L / Bilateral Trace 1+ 2+ 3+ Pitting / Non-pitting Location____________ Pulses: Radial: Strong / Weak / Not palpated/ Doppler / equal / _____ Respiratory: O2 @ __________L NC / Mask / NRB / Room air / Other ____________ FIO2: ________ L: ________ Breath Sounds: L: Clear / Diminished / Wheezing / Crackles / Coarse R: Clear / Diminished / Wheezing / Crackles / Coarse Increased WOB: Yes / No Cough: Yes / No Productive / Non-productive / NA Name_________________________ Clinical Reasoning Map Date______________ Pedal: Radial pulses: Strong / Weak / Not palpated/ Doppler / equal / _____ Treatments: IS / SVN / Suction: GI: BS: Hypo / Active / Hyper Assess: Nausea / Vomiting: ______ Last BM: _________ Consistency/ Color: _________________ Abd: Soft / Tense / Firm / Non tender / Tender / Distended GU: Voiding / Foley / Incontinence / Anuria Clear / Cloudy / Yellow / Amber / Bloody / Other: ______________ BR / Urinal / BSC / Bedpan / External Cath M/S: Upper Strength _____/5 in RUE / RLE Lower Strength _____/5 in LUE / LLE Weak/ Numb / Decreased ROM / Other: Gait: _____ Skin/Wounds Description: Location: IV: Site: _____ Gauge: _____ Saline-locked: Yes / No Maintenance Fluid: _____________ Rate: ________ Date placed: _____ S&S of infiltration or phlebitis: Yes / No Action: ______ Precautions: Fall / Bleed / Contact / Airborne / Droplet / Protective Name_________________________ Clinical Reasoning Map Date______________ Complete Lab section if appropriate. In the event your patient does not have labs simply put NA in the box. Lab Result Date/Time PT/INR PTT Blood Glucose 1. ______ 2. _____ 3. ______ 4. ______ 1. _____ 2. _____ 3. _____ 4. _____ ABG pH PaCO2 HCO3 Diagnostic Tests: Name_________________________ Clinical Reasoning Map Date______________ Pathophysiology (: Complications/Potential Complications (Risk Reduction): Psychosocial Concerns (Psychosocial Integrity): Name_________________________ Clinical Reasoning Map Date______________ Recognizing Cues: Assessment findings that warrant further investigation (VS/Subj./Obj./Labs/Diagnostics/Risk Factors/Psychosocial): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **May have more than 10 cues Prioritize Hypotheses: These are your Nursing Problem Statements. What do you think is the highest priority? What is it related to? Is it an actual problem or a risk problem? Take Action: These are your interventions. What will you do to help improve your client’s condition or prevent further deterioration? (Basic care & Comfort, Safety and infection control, Pharmacological therapies, Education, Health promotion, and management of care): Generate Solutions: Planning and goal setting. What do you want as an outcome for your client? Goals should be SMART goals. Analyze Cues: What do you think might be going on with the client? What does it mean? This is where you analyze the data you collected: Evaluate Outcomes: Did your actions result in the desired outcome for your client? Name_________________________ Clinical Reasoning Map Date______________ Medication Name (Generic) and Drug class Patient’s Dose, Route, and Frequency Why is patient receiving this medication? Nursing considerations (labs, assessment, etc.) Side effects and Major adverse effects Patient Teaching Name_________________________ Clinical Reasoning Map Date______________ Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care): Summary Report to Healthcare Provider (SBAR Format): SBAR- Health Science Science Nursing NUR 355 Share QuestionEmailCopy link Comments (0)
