Client Assessment Forms
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 …show more content…
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 …show more content…
This form is to be completed if you are not doing a formal care plan on this client. It is not necessary to include references.
Assessment | Diagnosis | Planning | Implementation | Evaluation | | | | | |
Medication Flow Sheet
Medication NameBrand & Generic | Classification | Mode of Action | Reason For This Client To Take The Medication | Side Effects | | | | | |
Laboratory Tests (May attach a separate sheet) Test | Norms | 1st Value Date | Results Date | Why are the results out of the norms and how will it affect your nursing care | Red Blood Cells | | | | | White Blood Cells | | | |
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 …show more content…
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 …show more content…
This form is to be completed if you are not doing a formal care plan on this client. It is not necessary to include references.
Assessment | Diagnosis | Planning | Implementation | Evaluation | | | | | |
Medication Flow Sheet
Medication NameBrand & Generic | Classification | Mode of Action | Reason For This Client To Take The Medication | Side Effects | | | | | |
Laboratory Tests (May attach a separate sheet) Test | Norms | 1st Value Date | Results Date | Why are the results out of the norms and how will it affect your nursing care | Red Blood Cells | | | | | White Blood Cells | | | |