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Embed code for: 2016 Client Assess (1)
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CLIENT PSYCHOSOCIAL / CULTURAL ASSESSMENT
STAGE OF GROWTH AND DEVELOPMENT (Erikson):
(Give supporting evidence for G & D level. DO NOT DEFINE THE STAGE)
RELIGIOUS PREFERENCE: MARITAL STATUS:
LIVING SITUATION: (Home/ alone or with family/ SNF/ Nursing home/ etc)
PRIMARY LANGUAGE SPOKEN: BARRIERS TO COMMUNICATION:
CULTURAL/SPIRITUAL BELIEFS, PRACTICES, CONSIDERATIONS:
(This is not religious preference)
OCCUPATION: Probable relationship with diagnosis, if any:
(If retired or disabled, what work was done during working years?)
DO FINANCIAL CONCERNS INFLUENCE CLIENT’S ABILITY TO SEEK MEDICAL CARE OR OBTAIN MEDICATIONS
(Use assessment skills and terminology learned in psych/mental health nursing)
For all medications administered on DOC (2400 – 2359) include time, dosage/route, and nursing implications.
MEDICATION NAME (GENERIC/TRADE)
CLASSIFICATION & DRUG ACTION
(Drug action explain in your own words)
REASON YOUR CLIENT IS TAKING MEDICATION
(ask the client)
Labs to be monitored
Side effects, most common & life threatening
DIABETES INFORMATION (This information should be gather by dialog with your client. Diabetic teaching may be indicated.)
Type 1: Type 2: Not Applicable
Number of Years:
Current Treatment (Diet/oral meds/insulin/combination):
Diabetic Complications Assessment
Retinopathy: Yes No
Glasses/Current vision issues Last eye exam Patient understanding of need for eye exams/compliance/barriers:
Diagnosed with renal disease: Yes No
Current GFR/Cr Clearance:
Is urine positive for protein (recent lab work): Yes No
Is client on an ACE inhibitor: Yes No If yes, name of medication:
Hx. of MI/angina/stent placement:
Dx. of CHF: Yes No
Dx. of dysrhythmias: Yes No If yes, what dysrhythmia?
Evidence of peripheral vascular disease?
History of foot ulcers/current foot ulcers?
Structural deformities in feet (hammertoe, Charcot’s foot, bunions):
Does client do a daily foot exam Yes No
Does client understand/barriers?
Dry skin/calluses present: YesNo Describe:
Impaired ability to detect hypoglycemia: Yes No
Impaired sensation in lower extremities or upper extremities: Yes No
Gastroparesis: Yes No
Record abnormal lab values, along with the admission value of that lab.
HEMATOLOGY and COAGULATION STUDIES
Initial Value (date: )
Current Value (date: )
Partial Thromboplastin Time
Analyze abnormal results and trends. What should the nurse consider/ plan/ implement related to these lab findings?
COMPREHENSIVE METABOLIC PROFILE (CMP)/ AMMONIA/ LIVER FUNCTIONS
Liver Functions (LFT)
CARDIAC RISK ASSESSMENT/ HORMONE ASSAYS
Serum Drug Levels
ARTERIAL BLOOD GASES
ALL OTHER LABS
Analyze abnormal results and trends. What should the nurse consider/ plan/ implement related to these findings?
Initial Findings/Impressions (date: )
STUDENT SELF ASSESSMENT
PATIENT TEACHING PLANNED/ COMPLETED (IF NONE DONE, WHY NOT)
SELF EVALUATION: Discuss your day (not details) in terms of how it impacted your nursing education.
What did you learned and what did it make you want to learn more about or do better?
What did you do well?
SKILLS PERFORMED AT CFE
NURS 2410/2420 CLIENT ASSESSMENT
Review Jan 2015 KEH ;Revised 12/15team