Westchester Community College
Nursing Assessment
10/13/2022 Patient’s
Student’s Name_____________________ Date__________
Initials________________________
strawberry
Allergies_______________
I. History
1. Family Status:
Marital Status divorced
Family Composition (ages) 3 sons (52,49,47), daughter(46)
Impact of disease on client and/or family 52 yr old son decesed
surviving children active in care and recovery. Illness has been stressfull for the
client ______________________________________________
and family.
2. Ethnic/Cultural Background:
Cultural/Religious Traditions related to health
Greman/swiss
chatholic/attends mass on sundays
3. Discharge Planning:
Living arrangements lives with son private house with few stairs to enter.
Safety needs at home assessment pending
4. Education Level:
English
Primary language spoken________________
N/A
Secondary language spoken_____________
Formal education grade 12
Daycare worker
Past/Present Occupation___________________________
5. Financial Status:
Type of health insurance
Medicare
Babysits
6. Recreational/leisure-time activities: Type______________
Amount some nights and weekend
no present signs of stress
7.Overt/Covert signs of stress______________________
Tobacco use::
1 pack per week
#cigarettes/packs/day_________
60yrs
# of years smoking___________________
N/A ___drinks/day _________Time
Alcohol: type- _____
of last
0
N/A
drink________
N/A
N/A
amount-_____________
Illegal drugs: type-_______
NO
8. Advance Directives: Living Will______
NO
DNR_______
Nursing Diagnosis R/T
II. Neurological Assessment
Nursing
Diagnosi
s R/T
1. Level of Consciousness: Alert____ Lethargic_____
Oriented: Person___ Place___ Time______
to:
If patient is not alert- patient responds
Pain
Touch_________________
2. Sensory: Pupils- Symmetry____, PERRLA_______
Vision- WNL____, Cataracts____, Glaucoma___Blind____
Glasses/Contact Lenses_______
clear
clear
Eyes- Color of conjunctivae________Sclera__________
Hearing impairment_________Hearing Aid____________
3. Communication:
Speech: clear___, garbled/slurred_____, non-verbal_____
speaks clearly but becomes winded easily causing gaps in speach
4. Thought Processes: in tact
Memory: short-term_____, long-term_____
Judgement cliant explained what she ate for breakfast and refrenced previos should surgery
is positive states "I will work
Client’s Perception of health status__________________
to get better"
becomes tired easily
Problems with adhering to medical regime: ______________
making
it
difficult
to
complete
PT/OT
_______________________________________________
currently needs help with ADL's involving
Problems managing ADL’s__________________________
bathing, dressing, ambulating,
______________________________________________
5. Motor Response:
Gait-steady, unsteady, shuffling 1 person assist ambulating from bed to WC
Muscle Strength-hand grasps: Strong______ Weak______:
Lower extremities: plantar/dorsiflexion: Strong______ Weak______
N/A
DTR Reflexes (If appropriate) Knee _________
Babinsky_______________
N/A
III. Respiratory
1. Rate
17
2. Depth-shallow_______ normal _______deep_______
Nursing
Diagnosi
s R/T
3. Rhythm-regular____-- irregular_______
pink
4. Skin/Mucous membrane color______________________
WC
5. Position___________________________________
6. Ease: Eupnea_____Dyspnea______Orthopnea________
Use of accessory muscles-Neck____ Abdominal____
Intercostals______ Retractions______
7. Nasal flaring Yes____________ No_______________
III. Respiratory (Cont’d)
Nursing
Diagnosi
s R/T
anterior & postierior
6. Lung Sounds: Clear ___Location__________________
Abnormal Type______________ Location_____________
____
7. Cough
N/A
Type
N/A
Frequency
Precipitating and/or associated factors N/A
Sputum-amount, color, consistency, odor N/A
N/A
N/A
Suction__________
Type_______________________
8. O2 Therapy:
nasal cannula
2L 28%FI02
Type________________
__ Concentration____________
Stoma/Dressing Yes___ No___ Type______________
9. Current Pulse Oximeter Reading
98%
____________________
10. Mechanical Ventilation:
N/A
N/A
E/T Size_________
Trach Size_________
N/A
Vent Settings_____________________
IV. Cardiovascular
1.
Radial Pulse
Apical Pulse
91
Rate
91
regular
Rhythm regular
strong
Strength strong
PMI of Apical Pulse regular
Nursing
Diagnosi
s R/T
yes
2. Hear Sounds_________________________________
3. Cardiac Monitor:
N/A
Rhythm________________________________________
2. Peripheral Pulses:
Presence
Lower Extremities:Dorsalis Pedis present
Posterior Tibial present
present
Popliteal
present
Femerol
present
Upper Body:
Brachial
present
Carotid
Quality
strong
strong
all peripheral pulses
checked bilaterally
except carotid
strong
strong
strong
strong
3. Neurovascular Assessment of Lower Extremities 5 P’s:
No
Normal
(color)____________________
Presence of Pain___________Pallor
No
present
Pulses_________Paresthesia
(lack of sensation)_______
<3
Perfusion (capillary refill, temperature) ________________
skin was warm to touch
______________________________________________
4. Blood Pressure:
Lying Sitting 135/82 L/arm
Standing
Pulse Pressure strong
5. Edema:
L+R Lower Extremities
Type-pitting_______ non-pitting____Location__________
_______________Amount +1____+2____+3____+4____
Jugular vein distention _______Y___________N
V. Nutrition
Pink
1. Buccal Cavity: Condition of gums_____________
tid
missing teeth______
Teeth- hygiene__________cavities______
caps_______ dentures_________
2. Appetite: Percentage of meal eaten today____________
75%
3.Usual pattern of food intake at home-likes, dislikes, culture, religion, food
Strawberry allergy
allergies____________________________
_______________________________________________
eat, meats, vegetables, fruits, and grains regulary
160cm/ 5'3" Weight______________
73kg/161.1lbs
4. Height_________
7. Use of IV (Parenteral Fluids/ Nutrition):
Primary Line- PICC LUE
N/A
Type of solution_______________________________N/A
Meds added to primary line_______________________
Nursing
Diagnosi
s
N/A
N/A
Amount of IV Fluid ordered_________Amount
LIB______
N/A
IVPB Med:____________________________________
N/A
Rate of Flow-gtts/minute________
Expiration date of bag
N/A
n/a
n/a
________
IV Pump/Controller____Setting_________mL/hr
Site-location___________color
___________pain_____
LUE
good
no
temperature______________
noraml/ 98.7
VI. Elimination - Bowel
no
swelling____
Nursing
Diagnosis
R/T
1. Usual elimination patterns before hospitalization
Time of last B.M _________________________________
0800
2. Bowel Sounds-location____________
quality- WNL_____
normal
hyperactive________hypoactive_______________
VI. Elimination - Bowel (Cont’d)
medium
brown
3. Characteristics of stool-amount_______color___________
consistency___________
unusual constituents____________
firm
N/A
Nursing
Diagnosi
s R/T
N/A
4. Ostomy: Type_________________________________
N/A diarrhea______
5. Abnormalities-constipation_____
bleeding____incontinence______
use of medications in the hospital- name of
med___________effectiveness___________
VII. Elimination - Urinary
1. Usual elimination pattern at home
Regular has bowel movement daily
regular
pale yellow
2. Characteristics of urine-amount_______color___________
clear_________ cloudy___________
N/A
3. Urinary Diversions:_____________________________
N/A
4. C.B.I_____________________________________
5. Abnormalities-anuria____ oliguria____ polyuria___retention
_____Incontinence_____dribbling_____frequency_____
Nursing
Diagnosis
R/T
bleeding____pain____
Urinary drainage catheter-Type________
VIII. Integumentary
Size______
Nursing
Diagnosi
s R/T
clean
good
warm condition1.Skin:hygiene______color_______temperature______
moist____dry____oily_____pruitis_____
2. Pressure Ulcer- type (stage) N/A
_____size_____location___
______________color________discharg
e-type___________
amt_____color______________odor______________
3.Bruises_____Lesions_______ Rash___________________
2inches
Location___________________Size_______
RUE, R/neck,
dark
purple
no
Color__________Drainage________________
yes
4.Surgical Incision___________
(roughly 8") sutures__________
no removed
location_____________size__________
sternum
healthy pink skin Drains present
no
staples______appearance
of incision/lesion__________
type______location___________________
drainage-type__________amt______color_______odor_____
5.Dressings-type________________
location_______________
no dressing
condition__________________________________________
6.Skin Turgor-normal____delayed___ normal for age______
7. Hair: Grooming-well groomed______unkempt___________
Texture-fine_______thick_____coarse________________
Distribution- thinning___location_____well distributed_____
8. Nails: Grooming-clean___neat_________dirty_______
Color-pink____pale_____cyanosis_______________
Texture-smooth______rough______brittle__________
<3
Capillary refill__________Clubbing/abnormalities_______
IX. Mobility
1. Current Mobility Status: Complete Bed Rest (CBR)_______ Bathroom
Privileges(BRP)________Out of Bed(OOB)_______
Usual exercise pattern:______________________________
sedentary
2. Use of supportive aids- number of people needed
person assist
1
for transfer_____crutches_____
braces____type__________
Nursing
Diagnosis
R/T
location_________ walker______wheel chair___________
WC needed to preform
Ability to use supportive aids effectively_________________
ADL's. FALL RISK, 2 person transfer
________________________________________________
3. Posture-erect, straight____ Curvature of spine - kyphosis, scoliosis,
lordosis
N/A
Balance_____________________________________
4. ROM-all joints active________, passive________________ contracturestype______, location______________________
5. Abnormalities-loss of extremity____________
castN/A
type_________location______________
Traction- type/location_____________weight___________
Tremors-location______________________________
Paralysis- location_____________________________
X. Rest, Sleep, Comfort
back
1
1. Pain- location,____________severity(0-10),____________
throbing dull
daily
_duration___________,character_______________________
precipitating or associated factors
Limited ROM from illness causing discomfort
_______________________________________________
PO medication
2. Use of supportive measures for pain-medications________________
pattern
PRN
of use_____________
effectiveness
PT light massage
other supportive measures for pain- type______________
daily
pattern of use ______________effectiveness______________
work well
3. Usual sleep patterns at home
regular sleep patternt/ wakes at 0700 goes to sleep at 2100
4. Sleep patterns in the hospital
sleep distubence present, room traffic, bed not comfortable.
N/A
5. Use of supportive measures for sleep -medications________________
pattern of use_____________
effectiveness
other measures for sleep- type________pattern of use_____
effectiveness____________
Nursing
Diagnosis
R/T