Individual
Assessment
Tool
NURS 206 – Nursing Practice
2017/2018
Individual Profile
Initials:
Age:
Sex:
Reason for Admission:
Medical Diagnoses:
Health History:
Allergies:
MEDICATION PROFILE –
Classification
Medication
Dose
Frequency
Parenteral Therapy
VITAL SIGNS & MEASUREMENTS –
Height
Pulse
Respirations
Weight
Oxygen Saturation
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Blood Pressure
Temperature
Route
NURS 206 – Nursing Practice
Diagnostic Tests
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Neurological System
Subjective Data & History
LOC
- alertness
Cognition
- orientation
- mood/affect
- thought content
- coherence
- memory
Spinal Nerves
Cranial Nerves
Pupils
- size
- symmetry
- reaction
- accommodation
Document assessment data on reverse
Document assessment data on reverse
Motor Function
- symmetry
- movement
- balance
- coordination
Sensory
Function
- touch
- sight
- hearing
- smell
- taste
Activity
Function
- ADL
- speech
- language
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Respiratory System
Subjective Data & History
Respirations
- rate
- rhythm
- depth
- exertion
Oxygen
- saturation
- therapy
Mouth & Nose
- patency
- secretions
Trachea
- position
Chest
- shape
- symmetry
Lung Auscultation
- air entry
- breath sounds
Cough
- type
- frequency
- secretions
Color
- lips
- nailbeds
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Cardiovascular System
Subjective Data & History
Pulses
- rate
- rhythm
- quality
- symmetry
Apical
Radial
Dorsalis Pedis
Posterior Tibialis
Blood
Pressure
CWMS
- colour
- warmth
- movement
- sensation
Capillary Refill
Heart Sounds
Rt. Arm & Hand
Lt. Arm & Hand
Rt. Leg & Foot
Lt. Leg & Foot
Rt. Fingers
Lt. Fingers
Rt. Toes
Edema
- location
- severity
Diagnostic Tests
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Medications
Lt. Toes
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Gastro-Intestinal System
Subjective Data & History
Nutrition &
Hydration
- diet: type & amount
- fluids: type &
amount
Oral Cavity
- mucosa
- colour
- moisture
- teeth
- chewing
- swallowing
- gag reflex
Abdomen
- contour
- symmetry
- bowel sounds
- soft/firm
Anus & Rectum
Stool
- frequency
- consistency
- colour
- odor
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Genito-Urinary & Reproductive System
Subjective Data & History
REPRODUCTIVE SYSTEM
Breasts
- symmetry
- nipples
- discharge
External Genitalia
Female
- labia & vagina
- discharge
Male
- penis & scrotum
- discharge
URINARY SYSTEM
Bladder
- size
Urine
- colour
- clarity
- odour
- amount
Voiding Patterns
- frequency
- force
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Musculoskeletal System
Subjective Data & History
Structure
- shape
- symmetry
- alignment
Skull & Face
Spine & Torso
Upper Extremities
Lower Extremities
Joints
- range of motion
Upper Extremities
Lower Extremities
Muscles
- movement
- strength
- symmetry
Face
Spine & Torso
Upper Extremities
Lower Extremities
Posture & Gait
- symmetry
- balance
- weight
- bearing
Activity
Mobility Aids
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
2017/2018
Individual Physiological Dimension
Integumentary & Lymphatic System
Subjective Data & History
Hair
- texture
- distribution
Nails
- colour
- shape
- texture
Lymphatics
- enlargement
Skin
- colour
- moisture
- temperature
- texture
- turgor
Identify any abnormalities using diagramming code:
A Abrasion
Br Bruising
R Rash
B Burn
Pu Pressure Ulcer
S Scar
W Wound
O Other (explain)
Wound
- characteristics
- discharge
- drains
Diagnostic Tests
Документ1
Medications
NURS 206 – Nursing Practice
Individual Physiological Dimension
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
Individual Physiological Dimension
Pain
Subjective Data
- acute
- chronic
Objective Data
Документ1
2017/2018
NURS 206 – Nursing Practice
Individual Physiological Dimension
Документ1
2017/2018
NURS 206 – Nursing Practice
Additional Assessment
Analysis
Документ1
2017/2018
NURS 206 – Nursing Practice
Nursing Diagnoses
Документ1
2017/2018