Davenport University/ Health Assessment: Fundamentals Student Name: Click or tap here to enter text. Assessment Date11/20/2021 Client InitialsL.H. DOB 10/23/1954 Code Status not on file Major Medical Diagnoses: Acute respiratory failure with hypoxia Allergies (Include-Severity/Reaction) Iodine-respiratory distress, Sesame oil-hives, Captopril Vital Signs: BP 170/90 Pulse 72 Temp 97.8 RR 20 SpO2 % 95% O2 In Use ☐Y ☒N Click or tap here to enter text.% Height 165.1cm Weight 86.2kg Pain Level: 0 Acceptable Pain Level Click or tap here to enter text. Duration: Choose an item. Location___________________________________________ Characteristics: Choose an item. Neurological/Cognitive LOC Mental Status: alert Orientation: person place time situation Speech: normal Respiratory Breath Sounds- State: ◻anterior wheezes ◻posterior_ wheezes Chest Symmetry ☒ Y ☐ N Rhythm: regular Cough: productive Smoker: ☐ History ☐ Present ☐Cigarettes/Day Click or tap here to enter text. YearsClick or tap here to enter text. Cardiovascular Rhythm: regular Skin: warm Capillary Refill: ☒ < 3 Seconds ☐ > 3 Seconds Pulses: Pulse Scale: 1+=Weak 2+=Normal 3+=Bounding Radial Right 2+ Radial Left 2+ Pedal Right 2+ Pedal Left 2+ Edema: ☒ None Severity /Location(S)(See Grid Below)__________________ Musculoskeletal/Activity/Exercise Limitations: ☐ none ☐weakness ☐fatigue ☒sob ☒Dizziness ☐syncope/Fainting ☐unsteady gait ☐paralysis ☐amputation ☐limited ROM Location: _________________ Hand Grip Equal & Strong ☒ Yes ☐ No Leg Strength, Equal & Strong ☒ Yes ☐ No Extremity Weakness: ☐ RUE ☐ LUE ☐ RLE ☐ LLE Mobility Status: ambulatory Assistive Devices: ☐ Cane ☐walker ☐ Crutches ☐ Wheelchair ☐ Prosthesis ☐brace ADLs: (I=Independent A= Assist D=Dependent) _I_feeding _I_toileting _I_ Grooming _I_ Dressing _I_driving _I_housework _I_cooking __I_Hygiene tub History of fall: ☐Y ☐N Fall Risk Assessment#= ___35__ (See Morse Fall Risk Scale) Morse Fall Score*High Risk 45 and Higher Moderate Risk 25 - 44 Low Risk 0 - 24 List Fall Prevention Interventions Fall socks, bed in lowest position, call light within reach Gastrointestinal/Abdomen/Nutrition Inspection normal symmetry Bowel Sounds present Complaints: ☐ Nausea ☐ Vomiting ☐ Diarrhea ☐ Constipation ☐ Incontinent ☐ Tarry, Black Stools Last Bowel Movement 11/18/2021 Nutrition: Diet:Cardiac Diet ☐Tube Feeding-Type__________________________ Choose an item. Fluid Restrictions: (How Many L)_____________________ Appetite: good ☐Discomfort ☒Difficulty Swallowing ☐Difficulty Chewing Has own teeth: ☒ Y ☐◻ N Dentures: ☐ Y ☒ N Oral Mucosa: ☒moist/Normal ☐lesions ☐sores Diabetes: ☒ Y ☐N Type: Choose an item. Blood Glucose Monitoring ☒ Y ☐N Frequency: AC & HS Latest Blood Glucose Level: 115 Genitourinary ☐Incontinence ☐kidney Stones ☐uti ☐renal Failure ☐ retention ☐nocturia ☐urgency ☐frequency ☐dribbling Dialysis ☐ Y ☒ N Date Of Last Treatment Click or tap to enter a date. Urine Color: clear Urine Odor: ☐ Y ☒ N Indwelling Catheter: ☐ Y ☒ N Date Placed: Click or tap to enter a date. Intermittent Catheter: ☐ Y ☒ N Date/Time Last Catheterization: Click or tap to enter a date. Female: Breast Cancer (Current or History) ☐ Y ☐ Side: Choose an item.Avoid BP On Affected Side! Male: Prostate Cancer (Current or History) ☐ Y ☐ N ◻ BPH ◻enlarged Prostate Skin Assessment Color: appropriate to ethnicity Condition: ☒intact ☒scar ☐rash ☐lesion ☐ecchymosis ☐Incision ☐ulcer (Pressure or Stasis) Davenport University/ Health Assessment: Fundamentals Student Name: Click or tap here to enter text. On The Chart Below, Identify Anatomical Locations Of Altered Skin Integrity & Place “#” To Designate Location Site #1 Description 20 G IV Hep Lock left AC Site #2 Description_Keloid scar to right anterior chest wall Site #____ Description_____________________ Site #____ Description_____________________ Labs CBC RBC_5.26___ Hgb __13.3__ Hct _42.7___ Wbc __25.9__ Platelets __286__ CoAg’s Inr/Pt ____ Ptt ____ Cardiac Trop _.08___ Bnp ____ ABGs pH _7.36___ pCo2 __46__ SaO2 ____ Chem studies Na+ __142__ K+ __4.0__ Cl- __107__ Ca++ __9.4__ Mg++ __2.0__ PO4 ____ Gluc _158___ HbA1c _6.4___ Bun _10___ Creat _0.99___ GFR __68__ Bili ____ ____ Albumin ____ Ast ____ Alt ____ Other Pertinent Labs: Vitamin D Hydroxy- 28, TSH- 0.25, F+4 0.9, BNP- <10 Nursing Notes: __Pt has barium swallow study ordered.___________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ _____ Student Signature: Tiffany Guyzik Date:11/20/2021 Client Interview: Communication/Learning: Primary Language: english ☐ Other Click or tap here to enter text. Reading Problems: ☐Y ☒N Recent Memory Changes: ☐Y ☒N Hearing: ☒no Problems ☐impaired ☐hearing Aids Vision: ☒no Problems ☐impaired ☐glasses ☐contacts Speaking: ☒ No Problems ☐ Dentures Easiest Way To Learn: ☒ Read ☒demonstrate ☐video/Tv ☐Pictures ☐groups ☐individual Instruction Readiness to Learn/Motivation: ☒asks Questions ☒eager To Learn ☒anxious ☐denies Need for Education ☐Uncooperative ☐unable To Assess Occupation Or Previous Job: Worked for GM Hobbies/Interests: Crossword puzzles Expectations or Concerns Regarding Your Hospitalization? No concerns. Pt stated very comfortable with hospitalization Who Do You Rely On For Support? No one How Has Your Illness Affected Your Family/Significant Other? No, it has not affected her relationship anyone Is Client’s Behavior Appropriate to Situation? ☐Y ☒N Have You Ever Suffered From: ☐depression ☐anxiety ☐Emotional Illness Cultural or Religious Practices Important To You during Your Hospitalization? ☒None ListClick or tap here to enter text. Catholic Communion ☐Y ☒N Advanced Directives: (E.G. Living Will, Durable Power Of Attorney) ☒Y ☐N ☐Would Like More Information Special Blood Transfusion Requests ☐Y ☒N Other Special Requests? ☐Y ☒N Click or tap here to enter text. Sleep: ☒no Problems ☐difficulty Falling Asleep ☐not rested After Sleep ☐otherClick or tap here to enter text. What Helps You Sleep? Nothing Sleep Routine: Bedtime @9:00pm_. # of Hours: 9. # Of Naps: 0 Other Observations: Click or tap here to enter text. Davenport University/ Health Assessment: Fundamentals Student Name: Click or tap here to enter text. Braden Skin Assessment Score 1 Sensory Perception Completely Limited Moisture Constantly Moist Activity Bedfast Mobility Completely Mobile Nutrition Very Poor Friction And Shear Problem Risk Assessment: low Risk = 15 – 18 * If Braden Scale score Is ≤ 14 Score 2 Very Limited Very Moist Chairfast Very Limited Probably Inadequate Potential Problem Score 3 Slightly Limited Occasionally Moist Walks Occasionally Slightly Limited Adequate No Apparent Problem Score 4 No Impairment Rarely Moist Walks Frequently No Limitations Excellent Client Score __4_ _4__ _4__ _4__ _3__ __3_ Client Score Total = ___ moderate Risk = 13 - 14 High Risk = ≤ 12 ◻ Dietician Referral Initiated by Whom________ Morse Fall Risk Assessment Risk Factor Scale Score History Of Falls Yes 25 No 0 Yes 15 No 0 Furniture 30 Crutches / Cane / Walker 15 None / Bed Rest / Wheelchair / Nurse 0 Yes 20 No 0 Impaired 20 Weak 10 Normal / Bed Rest / Immobile 0 Forgets Limitations 15 Oriented To Own Ability 0 Secondary Diagnosis Ambulatory Aid Iv / Heparin Lock Gait / Transferring Mental Status Total Score 35
