Patient Assessment

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GUIDELINES FOR CLIENT ASSESSMENT FORMS (CA)

A minimum of one or a maximum of two Client Assessment (CA) forms are to be handed in each week, at the end of your clinical rotation (post-conference) for that week. On the client you have chosen to do a care plan, the CA may be handed in with the care plan (the following week), however, all other clients' CA forms are due the week you gave care.

CA forms are to be completed (as much as possible) prior to client care and brought to pre-conference on clinical days. Clinical instructors will review your CA form to review your plan of care and clarify information, answer questions, etc.

Specific directions for the CA forms will be covered in orientation; however, some guidelines will be covered here for your reference.

Diagnosis (pathophysiology) - document the disease process, effects on the body, signs and symptoms and the reason why they occur, in detail. (This should come from a textbook such as the required medical-surgical or pathophysiology textbooks for the course not from a medical dictionary.)

Diet - be sure you understand the rationale behind a therapeutic diet and fill in the information required so that you will be prepared to do dietary teaching.

Treatments - should include any procedure done to this client by any health care worker (physician, PT, OT, RT).

Examples of Treatments:

Dressing changesHot & cold applications
SuctioningEnema/catherization care
Trach careIsolation
IPPBIntravenous therapy
Ambulation/ExerciseTube feeding
by physical therapistContinuous bladder irrigations
Percussion & vibrationOstomy care
CatheterizationsOxygen therapy/respiratory treatments
IrrigationsTraction/cast care/pin care

NOTE: State the reason why this client is receiving this treatment. Include the expected
therapeutic effects and any associated nursing interventions.

Medications - state the expected action in this client, why he/she is receiving it, and a few outstanding side effects and nursing interventions. This should not be a "copy" of your med cards! It should be the pertinent facts about the med that you will be taking into account while you are caring for this client.

Surgery and/or diagnostic tests - Fill in the information here that you will need to know and do, should a client have these done.

Client/Nursing Problems - choose three priority problems (either real or potential) that you anticipate your client will demonstrate. This problem list should come from your review of the chart (the day prior to care) and your research in nursing textbooks.

Example: Your client has leg ulcerations and Type 2 diabetes. When reviewing the client chart you find the client has 2 leg ulcerations both 2 cm in diameter. The client is complaining of burning pain in the right foot. When you read your textbook, you find that diabetic clients are at risk for injury due to peripheral neuropathy. Your goals and/or objectives should be very specific and written in client behavioral terms. The client problem form should reflect the care you plan to give the client that day

SAMPLE FOR CLIENT PROBLEMS/NURSING INTERVENTION

ASSESSMENT| PROBLEMS/NURSING DIAGNOSIS| GOAL/OBJECTIVE| NURSING INTERVENTIONS| EVALUATION| 4cm X 3cm wound on left leg | Impaired skin integrity related to peripheral artery disease a.e.b. leg ulcers| 1. The client will not develop any new ulcers in the next 24 hours2. The ulcer will decrease in diameter by 20% in 48 hours| 1. Change dressings and clean wounds as ordered.2. Inspect legs for signs of pressure or shearing forces.3. Protect skin from trauma| Ulcer is 4mm smaller than described in previous shift assessment. No new lesions noted. Goal met Con’t interventions| Pain level is 8 out of 10 per client report in both feet| Pain related to peripheral neuropathy a.e.b client’s report| The...
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