Short Form Care Planning Tool: RAM Assessment of Behaviors & StimuliStudent Name:
Date Assignment Completed:
Client (Code)
Primary Diagnosis
Past Medical History
Age
Primary MD
Past Surgical History
CODE Status
Vital Signs:
Time
T (route)
AP
R
B/P
Arm position ___________
R
O2 Sat
____ Room air
______ Oxygen therapy
Devise
____ l/ min
Comments:
Stroke
Seizures
Stomach
Ulcers
Mental Health
Problems
Kidney
Problems
Hypertension
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Environmental
Allergies
Anemia
Relationship
Cause
of
Death
(if
applicable)
Alcoholism
Family
Medical
History
Age (in years)
Pain: (0-10)
Current Medications (Including Herbal & Over the Counter)
Medication
Route
Dosage
Frequency
Immunization History:
Admission date:
Height:
Weight:
BMI:
Allergies: (Including environmental, food and medications)
Name of Agent
Reaction
System
Review Findings
GI/Nutrition
Diet:
•
–
How did you assist the client with their diet?
–
•
•
Normal Findings:
Bowel sounds active in all quadrants Abdomen soft,
non-distended, non-tender Receives and tolerates
nutrition and fluids
Absence of nausea, vomiting, cramping, diarrhea or
Constipation
No complaints of nausea, vomiting, or abdomen
pain with palpation
Feeding tube (include size and type)
Assess barriers to accessing nutritional food
Describe your Findings:
Intake:
Neurological
•
Respiratory
•
Describe your findings:
Normal Findings:
Regular rhythm, heart sounds S1 S2 present
Blood pressure baseline
Denies chest pain
Periorbital, sacral, pedal & generalized
edema absent
Skin warm & dry to slightly moist
Nail beds pink, capillary refill< 3 sec
Peripheral pulses palpable or present with doppler
Skin
•
Describe your findings:
Normal Findings:
Breath sounds clear and equal in all lobes.
Respirations regular, non-labored, without
use of accessory muscles
Mucous membranes pink
Chest excursion symmetrical
Trachea midline
If cough present, non-productive
Sputum clear or absent
Cardiovascular
•
Describe your findings:
Normal Findings:
Alert and oriented x 3
Speech is clear
Memory intact
Follows commands and converses
Absence of seizures
Behavior appropriate to situation
When upright: Balance steady Gross motor
coordination intact
Hand grasps strong/equal
PERRLA,
Foot presses and pulls strong and equal
Gag, cough, blink reflexes intact
Patient denies numbness tingling or other
paresthesia of extremities
Normal Findings:
Color normal for ethnicity
Temperature warm, dry to slightly moist
Turgor normal, mucous membranes moist
Skin intact without breakdown, rash,
redness
Describe your findings:
Wounds
•
IV Site (If applicable)
•
•
Peripheral IV:
Site
Size
Date Inserted
Fluids infusing yes/ no
• Type
• Amount
If no fluid, last time flushed
Central Access Device:
• Type of Device
• Date inserted
Fluids infusing- yes/no
Type
Amount
Mobility/Functional Ability
•
•
•
•
•
IV/ Central line (yes/no?)
Describe your findings:
Describe your findings:
Normal Findings:
Active ROM of all extremities within physical
limitations
Tolerates prescribed activity order
If ambulatory, gait steady
Able to complete ADL's
Able to transfer (with/without assistance)
List assistive device(s)
Determine if assistive devices are used correctly
Neurovascular assessment for client with cast or
traction
GU/Elimination
•
Wounds: (yes/no?) Findings:
Normal Findings:
Edges approximated and clean
Surrounding tissues free from signs &
symptoms of infection
Dressing dry & intact: drainage absent
Normal Findings:
Urine clear, straw to amber no unusual odor
Urine output within established parameters
Bladder non distended
Continent or incontinent of urine
If urinary devise is used, list (indwelling
urinary catheter, external female catheter,
condom catheter, suprapubic catheter,
straight catheter)
Describe your findings:
Output:
Psycho-Social
•
•
•
•
Pain, Comfort, Rest and Sleep
•
•
•
•
•
Describe your findings:
Assess Postpartum status
Assess the breasts
Assess Uterus (firm or boggy)
What is the fundal height
Is there bleeding (color and presence of clots)
Inspect the dressing and incision if C- Section
Assess Lochia (color, amount, number of pads
used)
Inspect the episiotomy ( redness or drainage)
Has the client voided (amount, color)
Has the client had a bowel movement
Assess bonding
Newborn Assessment (If applicable)
•
Describe your findings:
Assess Maternal status
Description of uterine activity
Assessment of Fetal status
Description of findings on vaginal exam, if
performed, including cervical dilation and
effacement, fetal station, change in status of
membranes, and progress since last exam
Postpartum (If applicable)
•
Describe your findings and identify scale used:
Normal Findings:
Rates pain ( may use numeric scale 1-10, WongBaker faces pain scale, FLACC scale, CRIES scale,
color analog scale, etc)
States and appears rested
Rests/sleeps during shift
Slept well during night
Obstetrics (If applicable)
•
Describe your findings:
Normal Findings:
Participates in two way conversation, care and
treatment plan
Able to communicate his/her needs
Coping mechanisms intact (client and family)
Mood/affect/behavior appropriate to situation
Assess client’s definition of health
Assess client’s understanding of current illness
What are the client’s resources for healthcare access,
access to housing and food, ability to afford
medications/ services and transportation to follow-up
and future healthcare visits?
Assess Newborn status
APGAR ( Appearance, pulse, grimace, activity
and respirations)
Weight/Length
Head and abdominal circumference
Skin (color, texture, nails, presence of rashes)
Head and neck (molding)
Fontanels
Genitals and anus (passage of urine and stool)
Describe your findings:
Pediatric Assessment (If applicable)
•
Safety: Describe your findings:
•
Describe your findings:
Assess Pediatric status
Assessment triangle (general appearance, work
of breathing and circulation of the skin)
Psychological, psychosocial and physical
development aligned with age
If Restraints used : Describe care
Normal Findings:
The physical environment is safe.
• Physical layout of client area
• Alarms
• Bed, IV
Current order for restraints
Identify Focal Stimuli (Focal stimuli, according to Roy (1983) are those stimuli that immediately confront the
individual in a particular situation. Example: Individual needs, the level of family adaptation, and changes in the
family environment.
Identify Contextual Stimuli (Contextual stimuli, according to Roy (1983) are internal or external factors that
influence the ability to respond to the focal stimulus and contribute directly to adaptation but are not the focus of
attention and energy.) Example: Other stimuli that may influence the situation- Coping mechanisms, diagnosis,
symptom severity and co-morbidities.
Identify Residual Stimuli (Residual stimuli, according to Roy (1983) are the additional environmental factors
present within the situation but whose effect on the client is unclear. Example: Beliefs, behaviors and personal
experiences.
Diagnostic Testing/Laboratory Data (CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.)
Teaching Needs Identified during the assessment (Behavior & Stimuli): Assessment of readiness to learn will
be completed as part of the Teaching Plan.
What teaching was reinforced during interactions with the client?
SBAR Report
Situation
Background
Assessment
Recommendation
Professional Nursing Care Plan
The following table provides information to utilize in developing your nursing care plans. Each column in the care plan form should include the appropriate information
related to the Nursing Diagnosis. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as noted on the page below. The Nursing
Diagnoses are then labeled in priority order where 1 would be the highest priority. (Nursing Diagnosis Priority #
) Any questions that you have concerning
the nursing care plans should be directed to your instructor.
(I) Data Collection Related to the
Nursing Diagnosis
Subjective
(Nonobservable)
Objective
(Observable)
Subjective data
should be clear,
concise and
specific to the
Nursing Diagnosis
Objective data
should be clear,
concise and
specific to the
Nursing Diagnosis
Subjective Data:
Objective Data :
What the patient or
family relates,
states, or
reports. (Nonobservable)
What is observed or
measured. May
include the client’s
behavior, vital
signs, lung sounds,
urine output,
laboratory data,
diagnostic testing
(etc.) as related to
the specific nursing
diagnosis.
(Observable)
1.
2.
3.
4.
(II) Complete NANDA
Nursing Diagnosis
(IV) Nursing
Interventions
(V) Scientific
Rationales
Best Evidence with
References
(VI) Evaluation of
Patient
Goals/ Outcomes
Choose a NANDA approved diagnosis.
The statement should list only one diagnosis and listed in the
following format, i.e., problem followed by "Related to (R/T)
the disease process
Manifested by: (signs and symptoms) is not part of nursing
diagnoses and should be written as a separate line.
Example: Coping, ineffective family: R/T Temporary family
disorganization and role changes. Manifested by significant
other's limited personal communication with client.
Each statement should be supported by a rationale
Should be:
1. Concise
2. Clear
3. Specific
4. Individualized
5. Accomplishable to
client and/or
family, significant
other.
1. Rationale should
address how
interventions are
going to solve the
problem and/or attain
the outcomes.
2. Rationale should be
specific to the
interventions, i.e., why
giving morphine 10
mg IV, why the client
is being turned and
positioned in proper
alignment every 4
hours.
3. Rationale can be
summarized in own
words and/or quoted
verbatim from
sources.
4. For every nursing
intervention, there
needs to be a
rationale.
Should address:
1. If the expected revised,
state how would revise
intervention.
2. What was the client's
response to
interventions?
(III) Goals/Outcomes
(Long and Short term) Including
timelines/timeframes
1.
Could have both short term and long term outcomes throughout
Nursing Care Plan (NCP), but each client should have one long
term goal as part of the NCP.
Definitions:
Short-term goals: Those goals that are usually met before
discharge or before transfer to a less acute level of care.
Long-term goals: Those goals that may not be achieved before
discharge but require continued attention by client and/or
significant others as indicated.
2. Each diagnosis, if appropriate, could have short-term goals and
long-term goals.
3. Statements:
Specific – relates to nursing diagnosis.
Measurable – tells what to see, hear, or smell.
Achievable – realistic for patient.
Clear and Concise – don't use “increase” or “decrease” without
giving baseline range of data.
4. Timelines (timeframes) for
achievement of goals:
Should be realistic and specific.
Give a date or time at which the expected outcome and nursing
interventions are achieved and/or evaluated.
Should specific as "by discharge date" or "on going."
Student Name:
Instructor: ________________________________
Client Code:
Nursing Diagnosis Priority #
Date:
Grade:
Professional Nursing Care Plan
(I) Data Collection Related to the Nursing
Diagnosis
Subjective
(Non-observable)
(II) Complete NANDA
Nursing Diagnosis
Objective
(Observable)
(III) Goals/Outcomes
(Long and Short term)
Including
timelines/timeframes
(IV) Nursing
Interventions
(V) Scientific Rationales
Best Evidence with
References
(VI) Evaluation of
Patient
Goals/ Outcomes
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