AE

Ga
Nursing Assessment sheet and Care Plan (one/rotation)

14.1 Physical Assessment Sheet (1)

Student’s Name: ...……………………………………. Date: ………………….

ID Number : ………………………………………….. Area: ………………….
1-Antenatal:
Personal & Social History:
Client’s name: …………………………….…. Age: …………Gender: ………………
Religion: ……………….. Occupation: …………………Date of Admission: ………….
Education:……………..Address:……………………MR No./Bed No. ……………
Family History:
Diabetes ( ). Hypertension ( ). Mental condition ( ).
Allergies ( ). Congenital Abnormalities ( ) Multiple pregnancy ( ).
Medical History
Heart Disease ( ) Kidney disease ( ) Hypertension ( )
STD ( ) Others…………………..
Surgical Operation ( ) If done, type:……………………………..
Menstrual History
Age at menarche ……………………….. Duration: …………………………..
Interval ………………………………… Rhythm: ……………………………
Amount: …………………….. LMP: …………………. EED: ……………….
Obstetrical History
Gravida: ………… Para: ………… Number of living children: …………..Abortion: ……….
Present History
Chief complaint: ………………………………………………………………………………
Observation: ………………………………………………………………………………….
Mother’s Reaction toward present pregnancy:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 42
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Physical Examination
General:
Weight: ………………….. Height: ………………………….
BP: ……………………….. Temp: …………………………….
Pulse: ……………………. Resp: ……………………………..
Breast and Abdomen:
Inspection of Breast
Size of Breast: ……………… Breast lump: ………………. Sign of pregnancy: ……………
Inspection of Abdomen:
FH: ……………… Lie: ……………………… Presentation: ……………………
Position: ………………….. FHR: ……………………..
Investigation
Urine Analysis:
Albumin ( ) Sugar ( )
Blood Analysis:
Hb ( ) Group ( ) RH ( )
VDRL ( ) Hepatitis B ( )
Others:
………………………………………………………………………………………………
2.Delivery:
Onset of contraction: ……………… Frequency: ……………… ……..
Duration: …………………… Cervical dilatation: ………………
Date and time of Delivery: …………………. Method: …………………………
Complication: ……………………….. Baby Sex: ………………………..
WT: ………………………………… HT: ………………………………
Congenital Abnormalities: ………………………………………………………….
3.Postnatal:
Bp: ………………………… HT: ……………………… WT: ………………..
Hb: ………………………… Brest Feeding: ……………………………………….
Abdomen: …………………. Uterus: …………………. Perineum: …………….
Family plan: ……………………………………………………………………………..
Special Note: …………………………………………………………………...............

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 43
Current Medications

Name Dose Route Action Side Effects

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Investigations
8
Diagnostic Test / Lab Test Results Normal Values Interpretation

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 Progress Notes
at
SOAP Notes
S= Subjective O=Objective A=Assessment P=Plan

Date Time Notes

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 46
14.2 Mini-Clinical Evaluation Exercise (Mini-CEX)
You would be expected to perform at least one (1) Mini-CEX/ Rotation which would involve a formal
evaluation by the preceptor or Clinical Instructor to ensure clinical competencies in a core competency
within the high dependency patient care areas. This could include history taking, physical examination etc.

Form 6: Mini-CEX Rating

Student Name:
Date:

Mini-CEX time: Min

Observing: Min
Providing feedback:

Assessment setting:
Communication skills
Inpatient Ambulatory ICU CCU Emergency department Other
Complexity:
Low Moderate Critical
High judgment

Description Unsatisfactory
Humanistic Satisfactory Very Good Excellent
0 quality/professionalism
1 2 3
1. Identify needs, actual and Identified 2 or less Identified 3 items Identified 4 items Identified the 5
potential problems for assigned items stated in the stated in the stated in the items in the
patient by the following: description
Organization anddescription
efficiency description description
1. Chief Compliant,
2. History of Present Illness
3. Past Medical History
4. Family History. Overall clinical care
5. Lifestyle/health practices
44. Utilize various data Did not utilize any Utilize 1 data Utilize 2 data Utilize 3 data
gathering techniques data gathering gathering gathering gathering
through: techniques techniques techniques techniques
1. Interview, nurse and client
2. Chart
3. Using IPPA

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 47
3. Perform a complete and Perform Perform Perform adequate Perform
focus nursing physical inadequate inadequate physical systematic
assessment effectively that physical physical examination that physical
covers all systems using examination examination covers all systems examination that
inspection, palpation, auscultation missing more than missing one to but did not focus on covers all systems
two systems two systems the identified and focus on the
problem identified problem

4. Understand Medications Identified 2 or less Identified 3 items Identified 5 to 4 Identified the 6

order by doctor and consider items stated in the stated in the items stated in the items stated in the
the following: description description description description
1. Generic name
2. Dose
3. Route
4. Action 1. g
5. Side-effect e
6. Nursing Intervention n
e
5. Review laboratory results Identified 1 or less Identified 2 items Identified 3 items Identified the 4 r
and consider the following: items stated in the stated in the stated in the items stated in the i
1. Lab test description description description description c
2. Lab results n
3. Normal values a
4. Interpretations m
e
Total
Suggestions for Development: 2.
1-
2-
Evaluator Name: Evaluator Signature

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 48
Nursing care plan

Date: ______________ Clinical Area: _______________________ Pt. Name: __________________________

Age: _________ Gender:________ Admitting diagnosis: _________________

History of present illness: ____________________________________________________________________________________________________

Assessment Nursing Diagnoses Expected Goals Nursing Interventions Rationales Evaluation
(Subjective and (Short term and (Goals met/ unmet)
objective data) long term
objectives)

stg

________________________________________________________________________________________________

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 49
 Is
Form 7: Nursing care plan rubrics
Items of Nursing Unsatisfactory Satisfactory Very Good Excellent
Diagnosis
0 1 2 3
Did not identify any actual/ Identified 1 actual/ potential Identified 1 actual/ potential Identified 2 or more
Assessment:
potential problem problem but incomplete and problem complete and correct actual/potential problem complete
Subject and object data
correct and correct data
Did not identify any nursing Identified 1 nursing diagnosis but Identified 1 nursing diagnosis Identified 2 or more nursing
Diagnosis: diagnosis incomplete and correct complete and correct diagnosis complete and correct
NANDA based data
Did not identify any goals Identified 1 LTO/ STO but not Identified 1 either LTO or Identified 2 or more LTO/ STO
Goals
correctly addressed STO and correctly addressed and correctly addressed
(SMART)
Did not identify any nursing Identified 1- 2 appropriate nursing Identified 3-4 appropriate Identified 5 or more appropriate
Nursing Intervention intervention interventions nursing interventions nursing interventions
Did not give any rational for Identified 1- 2 appropriate rational Identified 3- 4 appropriate Identified 5 or more appropriate
Rational the intervention for identified nursing rational for identified nursing rational for identified nursing
interventions interventions interventions
Did not identify any Identified 1 evaluation for Identified 1 evaluation either Identified 2 or more evaluation for
Evaluation evaluation identified LTO/ STO but not for LTO or STO identified LTO/ STO
correctly addressed
Total

Suggestions for Development:

1-___________________________________________________________________________
2-___________________________________________________________________________

Evaluator Name: _________________________ Evaluator Signature: ________

FCMS Bachelor of Nursing Program – NURS 304 Student Clinical Portfolio AY2022-2023 Page 50
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