Student Name: Vendula Stepan
Nursing Assessment Form
Client Name: F.V. 84 years old
Medical Diagnosis: SEE PATHOLOGY RECORD
Client Perception of Health Needs: Being as much independent as she can but needs assistance
with daily care.
Client Goals for Health: Maintain mobility and current condition, never give up on anything.
Allergies
(food, medication,
environmental)
Penicillin, Sulfa/Sulfonamide, Emycin base – hives, Procaine – swelling
blisters, Mold
SEE MEDICATION RECORD
Medications
Dietary
considerations
Regular
Vital Signs
T 36.3
P 73
R 16
BP 172/64
O2 97% RA
Pain rating 0
HEALTH ASSESSMENT DATA
Physiological Variable
General Appearance/Mental State:
Cardiovascular System:
Female, 84 years old. Appears stated age. No signs of
distress. Alert and oriented, confusion varies day by day.
Body type – well nourished. Affect and facial expression
appropriate to situation. Posture – slightly bent. Gait
unsteady and weak., Speech clear, understandable and
moderately paced.
Radial pulse regular, strong, no edema, capillary refill less
than 2 seconds, history of DVT
Respiratory System:
Gastrointestinal System:
Rate 16, air entry equal bilaterally, no crapitations or
wheezes, no supplementary O2 use, no accessory muscles
used.
Abdomen round and soft. Bowel sounds x 4. Regular bowel
movement.
Urinary System:
Sensory Systems:
Bladder incontinence, No pain or bladder tenderness reported.
Vision – both eyes impaired, wears glasses, family history
glaucoma, yearly check ups
History caract surgery
Hearing – no hearing impairment
Speech – preferred spoken language English, excellent ability
to follow directions
Student Name: Vendula Stepan
HEALTH ASSESSMENT DATA
Nervous System:
Integumentary System:
No tremors
Skin thin, pink, intact, dry, very fragile, often skin tears, no
edema
Musculoskeletal System:
Reproductive System:
Uses wheelchair
Unstable gait
Bilaterally hip replacement
One person Assist + using transfer belt
Postmenopausal
Tubal ligation
Endocrine System:
Client Resuscitation Status:
History of Tonsillectomy
M1 – medical care and interventions, excluding resuscitation
Spiritual Variable (Environment)
Developmental Variable (Environment)
According to the patient she is Christian, Attends all activities
provided in the long term facility – craft, board games,
making puzzles.
Married, retired, previous occupation a nurse, living in the
long term facility – single room, two kids –son Doug and son
David
Development stage according to Erikson’s Theory:
Integrity versus despair
Sociological Variable (Environment)
Psychological Variable (Environment)
Born in Canada, Primary language English enjoys any social
activities and loves to be involved in anything.
Support system her husband and two sons. Both sons living in
Camrose.
Determinants of health impacting client’s health (Environment)
My patient previous occupation was a nurse. The long term facility she resides in has positive influence on her health because
of the ability to socialize with other residents, with all the stuff and as well she is involved in the nursing environment. She
loves this socializing aspect and being around what she has done for her whole life. She is support for residence and always
tries to make them feel better if they don’t feel well. Every day she helps with small stuff such as folding towels.
Interdisciplinary Team Members
Physician- RN and LPN nurses, Nursing Assistants, Registered Dietitian ,Occupational therapist, Pharmacist, Resident Care
manager ,Chaplain
Health Priorities
-
Client stated: “Never give up on anything in your life especially your health. If you don’t feel well go and see your
doctor. There is always a way to get healthy and feel better.” Client also feels that being independent leads you to
better quality life.
Client Strengths
-
Client is very pleasant residence. She is very strong minded person and is very good influence for other residence.
Loves to socialize and being part of any activities happening in long term facility.
Student Name: Vendula Stepan
HEALTH ASSESSMENT DATA
Laboratory/Radiology Reports
7.4.2015
Chemistry – Creatinine 285 umol/l high, GFR 13 high
CBC – RBC – 3.85 10*9/L Low
HGB – 109 g/L low
HCT – 0.34 L/L low
15.05.2015
Xray of hand
Severe tissue swelling and some body erosions and surrounding the third and fourth finger DIP joints. It could
potentially be from trauma, or from goat, or less likely from infections. No soft tissue classification.
Student Name: Vendula Stepan
Pathophysiology Record
Must be written in your own words (i.e., as if teaching a patient)
Medical Diagnosis
Pathophysiology
Signs and Symptoms
High blood pressure – blood
pressure is the force of blood
pushing against the walls of the
arteries as the heart pumps blood. When
the blood pressure is too high it can cause
damage
Headache, blurred vision, nausea,
vomiting, weakness, fatigue, confusion
and mental changes
A weakness of the heart that leads to a
buildup of fluid in the lungs and
surrounding body tissues.
breathing difficulties during the night or
when lying down, coughing and
wheezing, fatigue and weakness, shortness
of breath, swollen ankles
Osteoporosis
Bones becoming fragile and brittle
Bone fractures especially in vertebra
Dementia other than Alzheimers
A chronic or persistent disorder of the 
mental processes caused by brain disease
or injury and marked by memory
disorders, personality changes, and
impaired reasoning.
Memory loss, impaired judgment,

Difficulties with abstract thinking, Faulty
reasoning, Inappropriate behavior, Loss of

communication skills, Disorientation to
time and place, Gait, motor, and balance
problems.
Hypertension
Congestive Heart Failure
1.
Complications
Stroke – rupture of cerebral
vessels due to hypertension
Pulmonary edema
Heart failure
Renal insufficiency – poor urine
output, protein in the urine, problems with
elimination waste
Shortness of breath, Orthopnea – shortness
of breath while lying flat, Paroxysmal
nocturnal dyspnea (PND) - sudden
episodes that awaken a patient at night,
fluid retention – edema and gain weight,
loss of muscle mass, loss of appetite,
pulmonary edema, abnormal heath
rhythms
Bone fractures
loss of ability to function or care for self,
loss of ability to interact with others,
reduced lifespan, increased infections
anywhere in the body, forgetting recent
events or conversations, difficulty
performing more than one task at a time,
forgetting details about current events,
difficulty swallowing both foods and
liquids
Student Name: Vendula Stepan
Pathophysiology Record
Must be written in your own words (i.e., as if teaching a patient)
Medical Diagnosis
COPD – emphysema
Gastrointestinal disease 2014 – GI bleed diverticulitis
Pathophysiology
Signs and Symptoms
Complications
All chronic obstructive lung problems
Irreversible enlargement of the air spaces
beyond the terminal bronchioles, most
notably in the alveoli, resulting in
destruction of the alveolar walls and
obstruction of airflow.
Disease of the large intestine, diverticulum
small sac forms along the wall of the
colon if it get infected - diverticulitis
Chronic hypoxemia - an abnormally low
concentration of oxygen in the blood,
hypercapnia - excessive carbon dioxide in
the bloodstream, chronic cough most in
the morning, dyspnea – difficult breathing,
wheezing, pursed lip breathing
Abdominal pain, fever, nausea, vomiting,
rectal bleeding
Pneumothorax – collapsed lungs, cor
pulmonare - a section of the heart expands
and weakens, right sided heart failure,
respiratory failure
Renal failure – chronic
Kidneys fail to adequately filter waste
products from the blood.

Abnormal dark or light skin, bone pain,
drowsiness or problems concentrating or
thinking, numbness or swelling in the
hands and feet, muscle twitching or
cramps, easy bruising, blood in the stool,
excessive thirst.
Goat
A disease in which defective metabolism
of uric acid causes arthritis, especially in
the smaller bones of the feet, deposition of
chalkstones, and episodes of acute pain.
Formation of one or more blood clots in 
one of the body's large veins, usually in
legs
Sudden onset of a hot, red, swollen joint
first in big toe, tenderness, hyperuricemia
– high blood levels of uric acid
DVT – deep vein thrombosis
pain, swelling and tenderness in one of the
leg (usually your calf), redness of skin,
warm in the area of clot
Bleeding, urinary problems, abscess - a
pus-filled cavity or lump in the tissue,
Fistulas are abnormal tunnels that connect
two parts of the body together, such as
your intestine and your abdominal wall or
bladder, peritonitis – infection of the
abdomen, intestinal obstruction
Anemia, hypertension – high blood
pressure, bone changes of secondary
hyperparathyroidism - an abnormally high
concentration of parathyroid hormone in
the blood, pulmonary edema, infections,
poor wound healing,
Joint damage, tophi - crystals of sodium
urate often form in tissues both outside
and inside the joint, kidney stones,
depression, anxiety
Pulmonary embolism, postphlebitic
syndrome - caused by damage to veins
from the blood clot
Student Name: Vendula Stepan
Nursing Process Care Plan (Use 1 sheet per Diagnosis)
Nursing Diagnosis
Planning
Interventions
Evaluation
Use assessment data to establish a
nursing diagnosis that reveals:
• an actual problem
• a potential problem
• an educational need or a need related
to medication administration
1. Client Goals: Write one specific and
measurable client behavioral response.
1. List Interventions:
Select nursing interventions to meet the
goals set, and to change or maintain
health status
1. Achievement of Expected Outcomes:
Assess goal achievement and reasons,
and set new plan as needed.
2. Client Responses and Findings:
Describe why goal was met of not met.
Summarize the effectiveness of nursing
interventions.
3. Further Nursing Actions:
Assess evidence that outcome was
met.
Readjust nursing care plan as
necessary.
Chronic pain related to chronic physical
disability as evidenced by gout.
Patient reports pain at a level 0-4 on a
scale 0-10 every day.
Assess pain characteristics – quality,
severity, location, onset, precipitating
factors, relieving factors
Patient didn’t experience any pain – pain
level 0 every day during my every day
shift.
Patient engages in desired activities.
Rationale :
Assessment of chronic pain guides the
pain management plan.
Goal was met because patient was taking
her pain medication on regular base and
was able to participate in desired
activities.
2. Expected Outcomes: Write
statements in measurable terms that
support the goal by using the SMART
criteria:
Specific
Measurable
Attainable
Realistic
Time-based
Patient uses pharmacological and nonpharmacological pain relief strategies.
2. Rationale for Interventions:
Provide rationale for selection of
nursing interventions and use
appropriate literature such as text,
articles, and internet sites to support
internet sites to support choices.
Assess patient’s ability to complete
activities of daily activity and demands of
daily living.
Rationale:
Fatigue, anxiety and depression due to
chronic pain and may affect activities and
reduce the patient’s ability to fulfill role
responsibilities
Encourage the patient to follow a pain
management strategy.
Rationale:
Medications should be given around-theclock to achieve consistent pain relief.
Student Name: Vendula Stepan
Nursing Process Care Plan (Use 1 sheet per Diagnosis)
Nursing Diagnosis
Planning
Use assessment data to establish a
nursing diagnosis that reveals:
• an actual problem
• a potential problem
• an educational need or a need related
to medication administration
1. Client Goals: Write one specific and
measurable client behavioral response.
Risk for falls related to decrease mobility
as evidenced by using a wheelchair.
Client will not experience any falls during
my shifts within one week.
2. Expected Outcomes: Write statements
in measurable terms that support the goal
by using the SMART criteria:
Specific
Measurable
Attainable
Realistic
Time-based
Client and I will make necessary physical
changes in environment such as maintain
proper illumination inside and outside
where the patient moves and walks, remove
clutter from bedside tables, hallways,
bathrooms and grooming areas, secure
electrical cords against the baseboards…..
to ensure increased safety within first week.
Interventions
Evaluation
1. List Interventions:
Select nursing interventions to meet the
goals set, and to change or maintain
health status
1. Achievement of Expected Outcomes:
Assess goal achievement and reasons,
and set new plan as needed.
2. Client Responses and Findings:
Describe why goal was met of not met.
Summarize the effectiveness of nursing
interventions.
3. Further Nursing Actions:
Assess evidence that outcome was met.
Readjust nursing care plan as
necessary.
2. Rationale for Interventions:
Provide rationale for selection of
nursing interventions and use
appropriate literature such as text,
articles, and internet sites to support
internet sites to support choices
Asses ability to use call bell, side rails, bed
controls, safety bars near toilets and proper
light.
Rationale:
“Easy modification in a health care
environment can reduce the risk of falls.”
(Potter & Perry, 2014, p. 810)
Routinely assist client in toileting on her own
schedule.
Rationale:
“Many falls by older adults are related to the
urge to urinate. Anticipate an older adults need
to urinate and provide scheduled bathroom
visits.”
(Potter & Perry, 2014, p. 1136)
Ensure that patient wears properly fitting shoes
or slippers with a nonskid surface.
Rationale:
“Such footwear reduces the chances of
slipping.”
(Potter & Perry, 2014, p. 811)
Client didn't experience any falls within
one week.
Goal was met because patient called
anytime when she needed any assistance,
had proper shoes on while I was
transferring her to her wheelchair and as
nurse I was coming regularly to check on
patient in case she needs to go to
washroom.
Student Name: Vendula Stepan
Nursing Process Care Plan (Use 1 sheet per Diagnosis)
Planning
Interventions
Evaluation
Use assessment data to establish a
nursing diagnosis that reveals actual /
potential wellness / problems.
• an actual problem
• a potential problem
• an educational need or a need related
to medication administration
1. Client Goals: Write one specific and
measurable client behavioral response.
2. Expected Outcomes: Write statements
in measurable terms that support the goal
by using the SMART criteria:
Specific
Measurable
Attainable
Realistic
Time-based
1. List Interventions:
Select nursing interventions to meet the
goals set, and to change or maintain
health status.
2. Rationale for Interventions:
Provide rationale for selection of
nursing interventions and use
appropriate literature such as text,
articles, and internet sites to support
choices.
1. Achievement of Expected Outcomes:
Assess goal achievement and reasons,
and set new plan as needed.
2. Client Responses and Findings:
Describe why goal was met of not met.
Summarize the effectiveness of nursing
interventions.
3. Further Nursing Actions:
Assess evidence that outcome was met.
Readjust nursing care plan as
necessary.
Decreased cardiac output related to
inadequate blood pumped by the heart as
evidenced by hypertension.
Maintain patient blood pressure within
acceptable range by taking medication to
control blood pressure within one month.
Monitor and record BP. Measure in both arms and thighs three
times, 3–5 min apart while patient is at rest, then sitting, then
standing for initial evaluation.
Rationale: Comparison of pressures provides a more complete
picture of vascular involvement or scope of problem. Systolic
hypertension also is an established risk factor for
cerebrovascular disease and ischemic heart disease, when
diastolic pressure is elevated.
Goal was not met. Patient’s blood
pressure still remains high.
Nursing Diagnosis
Client and I will discuses activities in which
client can participate in to reduce blood
pressure.
Client and I will talk about diet restriction decreasing dietary sodium, fat and
cholesterol.
Client and I will talk about medication
which she will take for her blood pressure
and its side effects.
Asses for edema
Rationale:
May indicate heart failure, renal or vascular impairment.
Assess the presence, quality of central and peripheral pulses.
Rationale:
Pulses in the legs/feet may be diminished, reflecting effects of
vasoconstriction (increased systemic vascular resistance
[SVR]) and venous congestion.
Observe skin color, moisture, temperature, and capillary refill
time.
Rationale:
Presence of pallor; cool, moist skin; and delayed capillary
refill time may be due to peripheral vasoconstriction or reflect
cardiac decompensation/decreased output.
Student Name: Vendula Stepan
Medication Research Record
Ensure you relate the medication information to the appropriate medical diagnosis.
Please use lay terms as if you were teaching a patient.
Medication/Reason for
Medication Order
Tylenol, Novo- Gesic Forte
acetaminophen 500mg tablet
Ventolin HFA
salbutamol 100 mcg/dose MDI
200
Lopresor, Betaloc, ApoMetoprolol
metoprolol 25mg tablet
La-A-Day, Miralax powder
polyethylene glycol 3350
powder
Dosage/Safe
Dose
Action as Related to Medical
Diagnosis
2xdaily
Oral
500 mg
8,20
Generalized pain – nonopiod
analgesics
Inhibits the synthesis of
prostaglandins that may serve as
mediators of pain and fever, primarily
in the CNS
Used as a long term control agent in
patients with chronic bronchospasm spasm of bronchial smooth muscle
producing narrowing of the bronchi
GI – hepatitic failure – failure of the
liver and hepatotoxicity – toxicity of
liver
GU – renal failure
Derm – rash, hives
Asses type, location and intensity of
pain
Asses amount , frequency and type
of drugs taking in patients selfmedicating, especially OTC drugs
CNS – nervousness, restlessness,
tremor
CV – chest pain, palpitations
GI – nausea, vomiting
Neuro - tremor
Assess lung sounds, pulse and blood
pressure
Monitor pulmonary function testes
before and during therapy
Decrease blood pressure and heart
rate by blocking stimulation of beta
adrenergic receptors.
CNS – fatigue, weakness, anxiety
EENT – blurred vision, stuffy nose
Resp – wheezing
CV – pulmonary edema, hypotension
GI – constipation, diarrhea
GU – urinary frequency
Derm – rashes
MS – back pain, joint pain
Monitor blood pressure and pulse
Monitor intake and output and weight
Treatment of constipation –
evacuation of the GI tract without
water or electrolyte imbalance
GI – abdominal bloating, cramping,
nausea
Assess patient for abdominal
distention, presence of bowel sounds
and usual pattern of bowel function
Assess color, consistency and amount
of stool produced
4xdaily
Inhalation
Inhale 2 puffs
8,12,17,20
2x daily
Oral
25mg
8,20
Daily
Oral
17 gm dissolve in
water or juice
8
Common Side Effects
Nursing Implications
Student Name: Vendula Stepan
Medication Research Record
Ensure you relate the medication information to the appropriate medical diagnosis.
Please use lay terms as if you were teaching a patient.
Medication/Reason for
Medication Order
Dosage/Safe
Dose
Action as Related to Medical
Diagnosis
Entrophen, Asaphen
aspirin 81mg tablec EC
Daily
Oral
81mg
8
For stroke prevention, reduce
inflammation and fever by inhibitin
the production of prostaglandins, also
decreases platelet aggregation
EENT – hearing loss, ringing in the
ears
GI – bleeding heartburn, nausea,
abdominal pain, vomiting
Misc – allergic reactions including
anaphylaxis and laryngeal edema
Assess pain
Monitor patient for toxicity and
overdose
Oscal, Novo-Calcium
Calcium salts 1250 mg
Daily
Oral
500mg
8
Adjunct in the prevention of
postmenopausal osteoporosis
CNS – tingling
CV – arrhythmias
GI – constipation, nausea, vomiting
GU - calculi
Daily
Oral
1000 unit
8
Vitamin D is a fat-soluble vitamin that
helps your body absorbs calcium and
phosphorus. Having the right amount
of vitamin D, calcium, and
phosphorus is important for building
and keeping strong bones. Vitamin D
is used to treat and prevent bone
disorders - Osteoporosis
Seen primarily as manifestations of
toxicity.
CNS – headache, weakness
CV – hypertension, edema,
palpitations, fast heart beat,
GI – constipation, dry mouth, nausea
Derm – hives, itching, rash
Assess patient for symptoms of
hypocalcemia
Monitor blood pressure and pulse
Monitor patient for toxicity and
overdose
Assess for symptoms of vitamin
deficiency
Assess patient for bone pain and
weakness
Assess patient for Toxicity and
Overdose – nausea, vomiting,
anorexia, weakness, constipation,
headache, bone paint and metallic
taste
Daily
Oral
100mg
8
Prevention of attack of gouty arthritis,
inhibits production of uric acid –
lowering of serum uric acid levels
CNS – drowsiness
GI – diarrhea
GU – renal failure
Derm – rash
Hemat – bone marrow depression
Misc - hypersensitivity reactions
Vitamin D3
Cholecalciferol 1000 unit tablet
Zyloprim, Novo-purol
allopurinol
100mg tablet
Common Side Effects
Nursing Implications
Monitor output and intake
Assess patient for rash or any other
severe hypersensitivity reactions
Monitor for joint pain and swelling
Monitor serum uric acid levels, renal
and liver function tests
Student Name: Vendula Stepan
Medication Research Record
Ensure you relate the medication information to the appropriate medical diagnosis.
Please use lay terms as if you were teaching a patient.
Medication/Reason for
Medication Order
Risperdal
risperidone 0.125mg tablet
Coversyl, Aceon
perindopril 2mg tablet
Dosage/Safe
Dose
Action as Related to Medical
Diagnosis
Common Side Effects
Nursing Implications
Daily at bedtime
Oral
0.125 mg
20
Decrease symptoms of psychoses or
bipolar mania by antagonizing
dopamine and serotonin in the CNS
CNS – aggressive behavior, dizziness,
headache, increase dreams, increased
sleep duration, insomnia
EENT – visual disturbance
Resp – cough, dyspnea
GI – constipation, dry mouth
Derm – skin rash, itching
Misc – weight gain
Monitor patient mental status
Monitor mood changes
Monitor blood pressure and pulse
Monitor for extrapyramidal side
effects and neuroleptic malignant
syndrome – restlessness, muscle
spasm and twisting motions, mask
like face, rigidity, tremors, fever,
respiratory distress, seizures
Daily
Oral
2 mg
8
Management of hypertension – high
blood pressure - lowering blood
pressure and decrease development
of overt heart failure
CNS – dizziness, fatigue, headache
Resp – cough
CV – hypotension – low blood
pressure,
GI – taste disturbance, nausea
GU – proteinuria – protein in the
urine, renal failure
Monitor blood pressure and pulse
Monitor weight
Monitor blood - CBC
Student Name: Vendula Stepan
Nursing Care Plan - Summary
Describe the benefits of using the nursing process and the nursing concepts in your
assessment and nursing care.
Assessment:
The benefits of using nursing process and the nursing concepts in my assessment helped to organize my work step
by step and therefore assisted me to better understand what the appropriate outcome for my patient should be.
Nursing Care:
Proper assessment helped me to prioritize my nursing care resulting in better clarification of focusing on issues that
require priority. In relations to the assessment I made on my patient my priority was to focus on patients pain level
due to her medical diagnose - goat, control patients pain and therefore increasing better quality of life.