New Assessment Form 2

CAPITOL UNIVERSITY College of Nursing NURSING ASSESSMENT FORM A. Demographic Data Name of Client _________________________________________ Unit/Ward __________ Bed ________ Age _________ Sex _________ Civil Status _____________ Religion ___________________________ Date of Admission _______________________ Medical Diagnosis ____________________________________________ Examiner ________________________________ Information given by ________________________________________ B. Vital Signs Temp ___________ oral axilla rectal BP ___________  lying  sitting  standing Pulse ___________/ min.  regular  irregular Resp ___________/ min.  regular  irregular Height ___________ cm. Weight ____________ kg. C. Health Patterns Assessment: Complete information, including patient’s words. Indicate N/A if non-applicable. Circle, code, or check all findings as appropriate. 1. Health Perception and Health Management Pattern Reason for hospitalization/chief complaint ________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ History of present illness ______________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Previous hospitalizations/surgeries_________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________ What other health problems have you had? __________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Things done to manage health ____________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Statement of patient’s general appearance ___________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Tobacco use:  Yes  No Used to smoke ______________ packs/day for __________ years Alcohol use:  Yes  No Amount: _______________ Frequency: _________________ Duration: _____________ Coffee/Cola/Tea Intake:  Yes  No Amount: ___________ Frequency: ____________ Duration: _____________ Recreational/Illicit Drug use:  Yes Specify: _____________________  No Allergies:  Yes (list with reaction experienced)  No Food: __________________________________________ Medications:_____________________________________ Others: ________________________________________________________________________________________ Medications: NAME

DOSE

SCHEDULE

INDICATIONS

Have you been taking your medication(s) as prescribed? ________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

2. Nutrition and Metabolic Pattern Special diet? _____________________________________________ Supplements: ________________________________ Pattern of daily food/fluid intake (describe amount/quantity) ____________________________________________________ _____________________________________________________________________________________________________ Appetite: ________________________________________________ Wt. loss/gain? ________________________________ Nausea/Vomiting: _________________________________________  Hematemesis  Coffee-ground vomitus Food/eating discomforts________________________________ GI pain ___________________________________________ Nutritional state:  well-nourished  poorly nourished  obesity  cachexia Mouth: Lips:  pinkish  pallor  cyanosis  dryness/cracks  lesions: ________________________________ Mucosa:  pinkish  pallor  cyanosis Tongue:  midline  R/L deviation  atrophy  fasciculation Teeth:  complete  missing teeth  caries  dentures: ________________ Gums:  pinkish  pallor  bleeding  tenderness Pharynx: Uvula:  midline  R/L deviation Mucosa:  pinkish  pallor Tonsils:  not inflamed  R/L inflamed  R/L with exudate Posterior Pharynx:  inflammation/congestion Neck: Trachea:  midline R/L deviation Thyroids:  non-palpable  enlarged Skin:

 reddish

Cervical lymph nodes:  lymphadenopathy  tenderness Others:  neck enlargement  normal ROM  neck rigidity

General Color:  pinkish  pallor  jaundice  dusky  cyanotic  flushed  mottled Texture:  smooth  rough  others: __________________________ Turgor:  supple  firm  dehydrated  others: ___________________________ Temperature:  warm  cool  others: ______________ Moisture:  dry moist/clammy  oily Others:  petechiae  ecchymosis  hematoma lesions/rashes: ____________________________________  edema: ____ pitting ____ non-pitting ____ pedal: R/L ______ bipedal Grading: ____________

Wounds/drains/dressings: _________________________________________________________________________________ Intravenous fluids _______________________________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 3. Elimination Pattern Usual bowel pattern (describe character of stool, frequency, discomforts) ___________________________________________ ______________________________________________________________________________________________________ _________________________________________________________________ Date of last BM: ______________________  Melena  Hematochezia Any problems with hemorrhoids/incontinence? _______________________________________________________________ Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies” anti-diarrheals): _______________ _____________________________________________________________________________________________________ Abdomen: General :  superficial veins  straie  scars/lesions: ____________________ Configuration:  symmetrical  asymmetrical  flat  globular  protuberant  scaphoid Bowel Sounds:  normoactive  hyperactive  hypoactive  absent Percussion:  tympanitic  hypertympanitic  dullness at _________________________________  fluid wave  shifting dullness Palpation:  muscle guarding  direct tenderness  rebound tenderness  bladder distention  organomegaly: ___ liver ___ spleen  masses at _____________________________________ Usual urinary pattern (describe frequency, character, amount, problem in control, etc.) ________________________________ ______________________________________________________________________________________________________  dysuria  hematuria  nocturia  retention  flank pain  polyuria  oliguria anuria Excess perspiration/nocturnal sweats: _______________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________ ______________________________________________________________________________________________________ 4. Activity – Exercise Pattern Exercise Pattern? (Type, Regularity) _______________________________________________________________________ Leisure Activities? _____________________________________________________________________________________ Cardiovascular Status:  chest pain/radiation: _______________________  palpitations  dyspnea on exertion  orthopnea  paroxysmal nocturnal dyspnea  jugular vein distention Precordial area:  flat  bulging  tenderness  heave  thrill Point of Maximal Impulse (PMI) _____________________ Apical rate & rhythm _____________________________ Heart Sounds: distinct  regular  faint  irregular S1 < > S2 at the base S1 < > at the apex Others:  S3  S4  Murmur best heard at ________________  Pericardial rub

Peripheral pulses:  symmetrical  regular  absent  faint/weak  strong  bounding Capillary refill __________________________  clubbing Presence of Pacemaker/A-V Shunt/Hemodynamic monitoring ______________________________________________ Respiratory Status: Breathing Pattern:  regular  irregular  eupnea  hyperpnea  tachypnea  bradypnea  dyspnea: rest / exertion  use of accessory muscles  ICS retractions/bulging  pain on respiration Shape of Chest: Anterior-Posterior-Lateral Ratio AP_____: L_____  barrel chest  funnel  pigeon Lung Expansion:  symmetrical  R / L decreased/lag Vocal/Tactile Fremitus:  symmetrical  decreased / increased at _________________ Percussion:  resonant  dullness at ___________________  hyperresonant at ___________________ Breath Sounds:  vesicular  bronchovesicular at _________________  bronchial at __________________  rales/crackles at______________  wheezes at ___________________  rhonchi  pleural friction rub Cough:  productive  non-productive Sputum: color _________ amount________ consistency __________ O2 supplement/ventilatory assistance_______________________________________________________________________ Resp. tubes (e.g. ET, trach, chest tube – describe secretions/drainage)_____________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ____________________________________________________________________________________________________ Activities of Daily Living/ Mobility Status: Use the Activity Level Code below to assess ADL & mobility status ADL Status Mobility Status 0 – total independence Feeding ________ Meal Preparation_____ Bed mobility _____________ 1 – assist with device Bathing ________ Cleaning __________ Chair/toilet transfer________ 2 – assist with person Dressing _______ Laundry __________ Ambulation ______________ 3 – assist with device & person Grooming ______ Toileting __________ R.O.M. _________________ 4 – total dependence Reasons for ADL/Mobility limitation _______________________________________________________________________ Device used for assistance ________________________________________________________________________________ Exercise pattern (describe type, regularity) ___________________________________________________________________ Back and Extremities: Range of Motion:  full  symmetrical  decreased ROM (specify joint) _________________  Joint tenderness/pain  joint swelling at ________________  varicose veins  deformities _____________ Muscle tone and Strength:  equally strong  symmetrical in size  R / L Upper / Lower Atrophy  R / L Upper / Lower Paresis  R / L Upper / Lower Paralysis Spine:  midline  Kyphosis  Lordosis  Scoliosis Gait:  coordinated  smooth  uncoordinated  shuffling  staggering OTHER PERTINENT DATA _____________________________________________________________________________ ______________________________________________________________________________________________________ 5. Cognitive – Perceptual Pattern Level of Consciousness:  conscious  alert  confused  drowsy  stuporous  comatose  others_______ Orientation:  oriented  disoriented to : time / person / place Emotional state:  calm  worried/anxious  restless  others: ______________________________________ Appropriate behavior/communication: ______________________________________________________________________  dizziness  numbness  tingling sensation Head:  normocephalic  asymmetrical  enlarged  masses: _____________  others: ___________________ Facial Movements:  symmetrical  asymmetrical: lag at R / L Fontanels:  closed  sunken  bulging  open: specify _____________________ Hair:  fine  coarse  dry  normal/even distribution  alopecia Scalp:  clean  dandruff  lice  wounds/scars/lesions: specify_______________________________ Eyes: Lids:  symmetrical  R / L edema/swelling  R / L ptosis  lesions: __________________________ Periorbital region:  edema  sunken  discoloration Conjunctiva:  pink  pale  lesions  discharges Cornea & Lens:  opacity: R / L  lesions: __________ Sclera:  anicteric  subicteric icteric  hemorrhages Pupils:  equal: size _____mm.  unequal: R= _____mm. L= _____mm. Reaction to Light: R -  brisk  sluggish  fixed L -  brisk  sluggish  fixed Reaction to Accommodation:  uniform constriction / convergence  unequal constriction / convergence Visual Acuity:  grossly normal  farsighted  nearsighted  wears eyeglasses/contact lenses Peripheral Vision:  intact/full  decreased/ limited: _________________________ Ears: External Pinnae:  normoset  symmetrical  tenderness  lesions  gross abnormalities ______________ External Canal:  discharge: ___foul smelling ___ serous ___ purulent ___mucoid  Cerumen: ____impacted Tympanic Membrane:  intact Gross Hearing:  normal  decreased  symmetrical  R / L deafness Nose:  alar flaring

 shallow nasolabial fold

Septum:  midline

 deviated

 perforated

Mucosa:  pinkish  pale  reddish Discharge:  serous  mucoid  purulent  bloody Patency:  both patent  R / L obstruction  masses/lesions: describe __________________________________ Gross Smell:  normal/symmetrical  R / L olfactory deficiency Sinuses:  tenderness: ____ maxillary ____ frontal Cognition: Primary language _________________________ Speech deficit _____________________________________ Educational attainment ______________________________________________________________________________ Any learning difficulties? ____________________________________________________________________________ Any change in memory lately? ________________________________________________________________________ Pain:  no problem  problem ( describe location, type, intensity, onset, duration of pain) ________________________ _________________________________________________________________________________________________ Methods of pain management: ________________________________________________________________________ 6.

Sleep – Rest Pattern

Usual sleep/rest pattern: _______________________________________________________________________________ Adequate  yes  no Factors affecting sleep/rest: ______________________________________________________ Methods to promote sleep _____________________________________________________________________________ History of sleep disturbances ___________________________________________________________________________ 7.

Self-perception and Self-concept Pattern How do you describe yourself ? ________________________________________________________________________ Are there any ways you feel differently about yourself since you’ve been ill/hospitalized? __________________________ __________________________________________________________________________________________________ Description of non-verbal behaviors: ____________________________________________________________________ _________________________________________________________________________________________________

8.

Role – Relationship Pattern Marital status _____________ Age and health of significant other _____________________________________________ Age and health of children ____________________________________________________________________________ __________________________________________________________________________________________________ Illnesses in the family ________________________________________________________________________________ Live  alone  family  others: ___________________________________________________________________ Family feelings regarding illness/hospitalization ___________________________________________________________ __________________________________________________________________________________________________ Who are the people that will help you most at this time? _____________________________________________________ Occupation: (any stresses/hazards?) _____________________________________________________________________ Financial support system: ______________________________________________________________________________

9. Sexuality – Reproductive Pattern Any changes/problems with sexual relations? ________________________________________________________________ Female: Menstrual pattern:___________________________________ Problems/changes: ____________________________ Date of LMP _________________________ Pregnancy history ____________________________________________ Use of birth control measure  yes  no  N/A Type: _____________________________________________ Any problem with use ? ______________________________ Monthly self-breast exam  yes  no External Genitalia: Labia:  symmetrical  asymmetrical  lesions __________________  pinkish  discoloration  edema Urethra:  pinkish  red/inflamed Vaginal Orifice Discharge:  purulent  bloody  foul-smelling Others:  swelling  lumps/nodules Breast:  equal  unequal Surface:  smooth  retraction  dimpling  edema  lesions  tenderness  masses at _____________________  others: __________________________ Male: Prostate problems? _____________________________ Monthly self-testicular exam  yes  no Penis:  discharge ________________  nodules/growths/lesions  tenderness Scrotum:  equal shape w/ L lower than R  non-tender  R/L enlargement  R/L undescended testes  tenderness  nodules/growths/lesions Others:  hernia  hydrocoele 10. Coping – Stress Tolerance Pattern Have you experienced any recent stressful situations in addition to your illness/hospitalization?  Yes  No If “Yes”, please describe briefly _______________________________________________________________________ __________________________________________________________________________________________________ Are there any ways we can be of assistance? ______________________________________________________________ How do you usually manage stresses? ___________________________________________________________________ What do you do for relaxation? _________________________________________________________________________ Support groups/counseling resources used: _______________________________________________________________ Were they helpful? __________________________________________________________________________________ 11. Value – Belief Pattern

Religion ____________________ Is it important in your life? How? __________________________________________ __________________________________________________________________________________________________ Religious practices __________________________________________________________________________________ __________________________________________________________________________________________________ Will illness/hospitalization interfere? ____________________________________________________________________