Nursing Health Assessment

MINDANAO STATE UNIVERSITY Iligan Institute of Technology DEPARTMENT OF HEALTH SCIENCES NURSING HEALTH ASSESSMENT General Information Vital Signs When did you have your blood pressure checked last? ______________________________________ Do you know the reading? ____________________________________________________________ Heart Rate _____________ Height __________ (cm/feet, inches) (actual/stated) Respirations____________ Weight__________ kg/lbs.) (actual/stated) Do you have a thermometer? ____________ Do you have a scale? __________________________________________ Have you been in a hospital / health facility in the past 15 days? [ ] No [ ] Yes Name of facility/Nature of the Problem: ________________________________________________________________ Allergies / Sensitivities (medicine, food, dust, etc) Source ________________________________________ ________________________________________ ________________________________________ ________________________________________

Reaction _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________

Functional Health Patterns Health Perception/Health Management Pattern 1. Do you have any health issues that you would like to improve? _________________________________ ______________________________________________________________________________________ 2. Preexisting conditions, surgeries, procedures: ______________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3. Have you been exposed to any communicable diseases within the past year? [ ] No [ ] Yes _________________ 4. Medications taken at home (include prescription, over the counter, herbal remedies, vitamins) Name Dose/Frequency/Route Reason for taking 1. _______________ _______________________________ ________________________________________ 2. _______________ _______________________________ ________________________________________ 3. _______________ _______________________________ ________________________________________ 4. _______________ _______________________________ ________________________________________ 5. _______________ _______________________________ ________________________________________ 6. _______________ _______________________________ ________________________________________ 7. _______________ _______________________________ ________________________________________ 8. _______________ _______________________________ ________________________________________ 5. Do you experience any problems from your medications? [ ] No [ ] Yes What do you do about it?________________________ Nursing Diagnosis 6. Do you experience any problems buying your medications/supplies? Noncompliance [ ] No [ ] Yes If yes, explain: ________________________________ Risk for Injury 7. Have you ever had a blood transfusion? Health­Seeking Behaviors [ ] No [ ] Yes Reaction? (type) ____________________ Ineffective Health Maintenance 8. Did you have the following screenings done in the past year? Ineffective Protection [ ] Breast self exam [ ] Prostate check [ ] Vision check Risk for Infection [ ] Mammogram date: _____ [ ] Testicular check [ ] Glaucoma Effective Management of Therapeutic  [ ] Pelvic exam/Pap smear [ ] Rectal check [ ] Dental exam Nutritional – Metabolic Pattern 1. Do you follow a special diet? [ ] No [ ] Yes, ________________________________ 2. When was the last time you ate? ____________________________________ 3. Have you been asked to increase/restrict your fluid intake? [ ] No [ ] Yes _________ Amount __________________ /day 4. Dentures? [ ] Upper [ ] Lower [ ] Partial 5. Appetite [ ] Normal [ ] Increased [ ] Decreased 6. Do you have difficulty with? [ ] No [ ] Choking [ ] Smell [ ] Chewing [ ] Swallowing [ ] Tasting [ ] Following diet Related to: ________________________________________________ 7. Do you have? [ ] No [ ] Nausea [ ] Vomiting [ ] Indigestion [ ] Weight loss/gain ______ kg/lbs. [ ] Mouth [ ] Persistent fever Soreness 8. Skin/Mucosa Color: [ ] Pink [ ] Flushed [ ] Pale [ ] Mottled

[ ] Cyanotic [ ] Jaundiced

[ ] Ashen

Regimen Ineffective Management of Therapeutic  Fluid Volume Deficit Fluid Volume Excess Impaired Swallowing Impaired Dentition Nausea High Risk for Aspiration Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More than Body Requirements High Risk for Imbalanced Body Temperature Hypothermia Hyperthermia Impaired Skin Integrity Impaired Tissue Integrity Adult Failure to Thrive

Temperature/Moisture:

[ ] Warm [ ] Cool [ ] Hot/dry [ ] Cold/clammy Turgor: [ ] Normal [ ] ____________________________________ Edema: [ ] None [ ] Generalized [ ] Localized:____________________ (describe location and degree 1-4+) 8. Wounds/Drains/Tubes/Catheters/Dressings: [ ] None _______________________ _________________________________________________________________________ 9. Oral Mucous Membranes: [ ] Not Applicable [ ] Intact [ ] Lesions ______________________________________________ [ ] Moist [ ] Dry Color: [ ] Pink [ ] Pale [ ] Cyanotic [ ] Other________________________ 10. Braden Skin Risk Assessment Score 15-16 Low risk 13-14 Moderate risk 12 or less Severe risk Elimination Pattern Constipation 1. Are you having any problems with bowel/bladder elimination? Diarrhea [ ] No [ ] Yes, describe: __________________________________ 2. Abdomen Bowel Incontinence [ ] Soft [ ] Firm Altered Patterns of Urinary [ ] Nontender [ ] Tender: Location ____________________________ Elimination [ ] Nondistended [ ] Distended: Girth _____________________________ Urinary Retention [ ] Ostomies/tubes: type _______________________________________Total Incontinence Care (circle): independent, needs assistance Stress Incontinence Bowel Sounds [ ] Present [ ] Absent [ ] Other _______________________ Functional Incontinence Urge Incontinence 3. Bladder [ ] Nondistended [ ] Distended Comments: _______________________________________________________ _________________________________________________________________ Activity – Exercise Pattern Fatigue 1. Do you have enough energy for desired/required activities? [ ] Yes [ ] No 2. Do you need assistance with? [ ] Not applicable Activity Intolerance [ ] Eating/Drinking [ ] Walking [ ] Sitting Self­Care Deficit [ ] Toileting [ ] Getting up from bed/chair[ ] Preparing meals (specify) ________________ [ ] Bathing [ ] Stair climbing [ ] Shopping Impaired Home Maintenance [ ] Dressing [ ] Turning Impaired Physical Mobility Comments: _____________________________________________________ High Risk for Disuse 3. Mobility Impairments [ ] None [ ] Unable to assess [ ] History of falling [ ] Tremors/Spasms____________________ syndrome [ ] Dizziness [ ] Paralysis ___________________________ High Risk for Injury Risk for Falls [ ] Unsteadiness/Balance [ ] Decreased Function __________________ Impaired Physical Mobility [ ] Amputation_________ [ ] Numbness, Tingling, Burning _____________________ ________________________ [ ] Impaired limb _______ Risk Fall Assessment [ ] No Risk [ ] Low Risk [ ] High Risk Gross Motor Movements: Normal Abnormal Comments______________________________________ Gait [ ] [ ] _______________________________________________ Posture [ ] [ ] _______________________________________________ ROM [ ] [ ] _______________________________________________ 4. Do you use any assistive devices at home? [ ] No [ ] Yes 5. Muscle Strength (see Key) Muscle strength key [ ] Not applicable +5 = able to move against full resistance left arm _____ +4 = able to move against gravity and mod resistance right arm _____ +3 = able to move against gravity but no resistance left leg _____ +2 = weak movement, unable to overcome gravity right leg _____ +1 = flicker of muscle movement 0 = no movement 6. Respiratory Assessment Respiratory effort [ ] Easy [ ] Use of accessory muscles Respiratory pattern [ ] Regular [ ] Irregular: ____________________ Breath sounds Right Left Ineffective Airway Clearance Clear [ ] [ ] Impaired Gas Exchange Diminished [ ] [ ] Ineffective Breathing Patterns Coarse/Rhonchi [ ] [ ] Cardiac Output, Decreased Crackles/Rales [ ] [ ] Ineffective __________________ Wheezing [ ] [ ] Tissue Perfusion Absent [ ] [ ] Cough [ ] No [ ] Yes Sputum [ ] No [ ] Yes:_________________ ________________________ 7. Cardiovascular Assessment Rhythm_____________________ Heart Sounds________________ Neck Veins [ ] Flat [ ] Distended

Peripheral pulses (0 = absent, +1 = weak, +2 = normal, +3 = bounding Dorsalis Pedis Posterior tibial Radial Other Right _____________ ____________ ________ _______ Left _____________ ____________ ________ _______ Sleep – Rest Pattern Sleep Pattern Disturbance [ ] Not applicable Sleep Deprivation [ ] Deferred 1. Have you had difficulty sleeping prior to admission? [ ] No [ ] Yes, describe:____________________________________ 2. Difficulty falling asleep? [ ] No [ ] Yes 3. Early awakening? [ ] No [ ] Yes 4. Abnormal cycle of sleeping daytime sleeping [ ] No [ ] Yes awake at night [ ] No [ ] Yes Cognitive – Perceptual Pattern 1. Orientation Level of Consciousness Confusion, Acute [ ] Not oriented [ ] conscious Confusion, Chronic [ ] Oriented to Person [ ] lethargic, sleepy, drowsy Disturbed Thought Processes [ ] Oriented to person, place [ ] stupor – aroused by verbal stimuli Impaired Verbal [ ] Oriented to person, place, time but responds poorly to pain Communication [ ] light coma – no response to verbal stimuli Impaired Memory but responds to pain [ ] deep coma – no response to painful stimuli Sensory­Perceptual 2. Pupils [ ] Not applicable Describe:___________________________ Disturbed (specify)_________ High Risk for injury 3. Clarity of speech [ ] Clear [ ] Slurred [ ] Aphasic Primary language if not English:______________________________ Pain Acute 4. Thought Process [ ] Logical [ ] Illogical (confused) [ ] flight of ideas Chronic Pain 5. Deferred [ ] Knowledge Deficit What is the highest grade in school you have completed? _______ Occupation:___________________________________________ Do you have problems with your memory? [ ] No [ ] Yes ________________ Hearing Aid [ ] No [ ] Right ear [ ] Left ear Glasses/contacts [ ] No [ ] Yes Do you have any problem with your ability to feel pain, temperature? [ ] No [ ] Yes Describe:_______________________________________________________ Have you ever had a seizure? [ ] No [ ] Yes How often?__________________ Describe your seizure __________________________________________________ When was your last seizure?_____________________________________________ Do you have pain? [ ] No [ ] Yes If yes, (type, duration, location) Describe: __________________________________________________ How do you get relief from your pain? _____________________________________________________ What do you need to learn to be able to care for yourself after discharge?____________________________ ______________________________________________________________________________________ Self – Perception Pattern Self­concept Disturbance Behaviors indicate the following Body Image Disturbance 1. Mood [ ] Calm [ ] Agitated [ ] Angry Anxiety [ ] Anxious [ ] Sad [ ] Other _______________ Fear 2. Affect [ ] Normal [ ] Labile [ ] Flat Hopelessness 3. Verbal Style [ ] Interactive [ ] Quiet [ ] Talkative [ ] Guarded 4. What outcome do you expect from this hospitalization?___________________ ________________________________________________________________ Role – Relationship Pattern Interrupted Family Processes 1. Lives [ ] Alone [ ] With ___________________________________ Chronic Sorrow 2. Who will assist you with your care after discharge? [ ] No one Ineffective Role Performance ______________________________________________________________ Impaired Social Interaction 3. Resides: [ ] House [ ] Apartment [ ] Assisted [ ] Living Social Isolation [ ] 24 hour nursing care provided 4. Environmental/Safety concerns (stairs, inaccessible bathrooms, etc) [ ] NoneCaregiver Role Strain Grieving, Anticipatory Describe: _____________________________________________________ 5. Any current family difficulties of concern to you? [ ] None Describe: _________________________________________________________

Sexuality – Reproductive Pattern 1. Do you have any questions/concerns about the effects your physical condition Sexual Dysfunction Ineffective Sexuality Patterns or medications may have on your sexual activity? ________________________ [ ] No [ ] Yes ________________ 2. Females [ ] post menopausal date of last menstrual period?_____________________________

Coping – Stress Pattern Impaired Adjustment 1. Have you had any recent major life-style changes? [ ] No [ ] Yes, describe __________________________________ Ineffective Individual Coping 2. How do you deal with stressful situations? __________________________ Suicide, Risk for ______________________________________________________________ Post­Trauma Syndrome ______________________________________________________________ ________________________ _________________________________________________________________ Value – Belief Pattern 1. Religious preference:___________________________________________ Spiritual Distress 2. Are there any religious or cultural practices that may be affected by this ________________________ hospitalization? [ ] No [ ] Yes, describe____________________ 3. Would you like to see a Chaplain? [ ] No [ ] Yes 4. Advance Directives reviewed for completion [ ] No [ ] Yes Has patient discussed advanced directives with physician? [ ] No [ ] Yes 5. Further actions if applicable [ ] patient given additional information [ ] patient referred to [ ] social work [ ] pastoral services other_______