Nursing Initial Assessment Date: Time: □ Patient Informant: _ □ Other _________________________ Reason for Admission (Pt’s own words): __ Vital Signs T O R A T P Reg Irreg SaO2 R BP Ht BMI Wt Kg Allergies Allergies Reaction Allergies Reaction Allergies Reaction Latex? Y or N Chronic Conditions □ Lung Problems □ Stomach Problems □ Thyroid Problems □ Neurological Problems □ Heart Problems □ Liver Problems □ Vision Problems □ Kidney Problems □ Arthritis □ Diabetes □ Chronic infection Treatment: ________________________________ □ Cancer (Where/Type): ___________________________________________________________ Treatment: __________________________________________ Other Past Medical History and Surgeries: _______________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ □ Family History – □ NSF □ Heart Disease □ Hypertension □ Diabetes □ Stroke □ Seizures □ Kidney Disease □ Liver Disease Medications Medication (include OTC) Dose Frequency Taken today? Y or N Brought with? Y or N Medications (include OTC) Dose Frequency Taken today? Y or N Brought with? Y or N Social History □ Lives Alone □ Lives With: ______________________________________________________________________________ Stairs At Home? □ Yes □ No Sleep Pattern: _______________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Immunizations Current? □ Yes □ No Nicotine Use: Last Tetanus Toxoid: _______________________________________________________________________________ □ No □ Yes – How much? ___________________________________ How Long? ________________________________________ Do you live in a smoking environment? □ Yes □ No □ No □ Yes – How much? ____________________ How Long? ____________________ Last Drink? Alcohol Use: ______________________________________________ □ No □ Yes – Type? Social Drug Use: Frequency?__________________________________________________ Support Services: □ No □ Yes – Type □ HHC □ Hospice □ Other Additional Help needed? □ No □ Yes – Referral made to ___________ Impairment / Disabilities Yes No Yes Impaired hearing Hearing Aid Impaired vision Glasses Can perform ADL? Contacts Can read? Dentures Can write? Partial Yes No RL No Walker Crutches Wheelchair UL Cane Prosthesis Home O2 Rate: Other: Dietary Habits Special Diet: ________________________________________________________________________________ Supplements: _________________________________________________________________________________ Safety ID Band On? □ Yes □ No Oriented to Unit? □ Yes □ IV Pump? □ Yes □ No Toiletry Supplies Offered? □ Yes □ No No Call Bell Within Reach? □ Yes □ No Skin Integrity Assessment Scale: Fall Risk Assessment Scale: ______________________________________ _______________________________ If 17 or below, Skin Risk initiated. If above 25, Fall Prevention initiated. Skin Risk Assessment Scale: Sensory Perception Ability to respond to pressure related discomfort 1. Completely limited – unresponsive to pain or limits ability to feel pain over most of body 2. Very limited – response to painful stimuli or limits ability to feel pain over ½ of body, or paralysis present 3. Slightly limited – response to verbal command but can’t always communicate 4. No Impairment – able to verbalize feelings and complaints Moisture Skin exposed to moisture 1. Constantly moist – (i.e. perspiration, urine) 2. Very moist – extra linen change 1x per shift 3. Occasionally moist – linen change 1x per day 4. Usually dry – no extra linen changes Activity Degree of physical activity 1. ABR 2. Chair fast – NWB/WC must be assisted to chair 3. Ambulates occasionally – with assist up in chair 4. Ambulates frequently Mobility Ability to change and control body position 1. Completely immobile 2. Very limited – unable to make frequent changes independently 3. Slightly limited – makes frequent slight changes for self 4. No limitations Nutrition Food intake pattern 1. Very poor – NPO, Clear liquids, or IVs > 5 days. Takes fluids poorly. Underweight, malnourished. 2. Inadequate – eats < ½ meal. Takes less than optimum 3. Adequate – eats > ½. Tube feeding or TPN provides needs 4. Excellent Friction 1. Problem – requires assist in moving. Frequent friction. History of skin tears or pressure sores. 2. Potential – requires minimum assist, occasional friction 3. No apparent problem – BRP 4. Up ad Lib Fall Risk Assessment Scale: Confused – disoriented – hallucinating 20 Post-op condition – sedated 10 Narcotics, diuretics, antihypertensives, etc. 10 Unstable gait, weakness 20 Drug or alcohol withdrawal 10 Bowel, bladder urgency – incontinence 10 Hx of syncope or seizures 15 Use of walker, cane, crutches, etc. 10 Age 70 or above 5 Recent hx of falls 15 Postural hypotension 10 Uncooperative, impaired judgement 5 Age 12 or younger 15 Poor eyesight 10 Language barrier 5 Paralysis, hemiplegia, stroke 15 New meds (i.e. sedative, antihypertensive) 15 Poor hearing 5 Part II – Systems Review * NSF = No significant findings Check appropriate box if present – if box not checked, sign/symptom not present Eyes: □ WNL □ Yes □ No Blurred Vision □ Yes □ No Color Blind □ Yes □ No Drainage — Color □ Yes □ No Double vision □ Yes □ No Itching Amount □ Yes □ No Inflammation □ Yes □ No Pupils Abnormal □ Yes □ No Other □ Yes □ No Pain Ears: □ WNL □ Yes □ No HOH (R) (L) □ Yes □ No Deaf □ Yes □ No Drainage □ Yes □ No Tinnitus □ Yes □ No Sense of Balance □ Yes □ No Dizziness □ Yes □ No Pain □ Yes □ No Other Nose: □ WNL □ Yes □ No Congestion □ Yes □ No Nasal Flaring □ Yes □ No Drainage – Color □ Yes □ No Other Mouth: □ WNL □ Yes □ No Halitosis □ Yes □ No Sense of Taste Dental Hygiene Throat/Neck: □ WNL □ Yes □ No Sore Throat □ Yes □ No Stiffness □ Other □ Yes □ No Pain □ Yes □ No Alignment □ Yes □ No Pain □ Yes □ No Sinus Problems □ Yes □ No Nosebleeds – Frequency Amount □ Yes □ No Bleeding Gums □ Yes □ No Lesions Last Dental Exam □ Yes □ No Hoarseness □ Yes □ No Pain □ Yes □ No Lumps □ Yes □ No Dysphagia □ Yes □ No Swollen glands Neurological: □ WNL □ Yes □ No Cooperative □ Yes □ No Memory Changes □ Yes □ No Dizziness □ Yes □ No Headaches □ Yes □ No Oriented □ Yes □ No Other Oriented to: □ Yes □ No Person □ Yes □ No Place □ Yes □ No Time Pupils Size: Deviation: □ Yes □ No PEARLA Reaction: □ Brisk □ Sluggish □ No Response □ Alert LOC Speech □ Clear Grips: □ Confused □ Sedated □ Somnolent □Comatose □ Agitated □ Other □ Slurred □ Aphasic □ Dysphasia □ None □ Other: □ Other: Foot pushes: Gag reflex: Respiratory: □ WNL Lung sounds: □ None Dyspnea □ None Cough Chest Symmetry □ Yes □ Yes □ No Night Sweats □ Other: □ With activity □ At rest □ Lying down □ Retractions □ Non-productive □ Productive – Color Amount □ No – □ Barrel □ Funnel □ Other □ Yes □ No Hemoptysis □ Yes □ No Cyanosis – Where Cardiovascular: □ WNL Cardiac Rate or Monitor pattern: □ Yes □ No Chest Discomfort – Where: Duration □ Yes □ No Pulse Radial (R)/(L) □ Yes □ No Pulse Pedal (R)/(L) □ Yes □ No Edema – Location □ Yes □ No Pacemaker – Date Inserted Type: □ Yes □ No Murmur □ Regular Intensity (1 – 10) Resolution □ Irregular □ Irregularly irregular Onset □ Yes □ No JVD (R)/(L) □ Non-pitting Where: □ Pitting Skin – Extremities – Musculoskeletal: □ WNL □ Warm □ Cool □ Dry □ Firm □ Flaccid Skin Color: □ Yes □ No History DVT □ Yes □ No Homans (R)/(L) Extremities □ Yes □ No Tingling □ Yes □ No Weakness □ Yes □ No Deformity Joints □ Yes □ No Pain □ Yes □ No Stiffness – Location: □ Yes □ No Replacement – Date Where: □ WNL □ Other (location/ range): ROM □ Yes □ No Contractures Physical Findings: □ WNL Describe and graph all abnormalities by number: 1. Bruises 2. Incisions 3. Lacerations 4. Rashes 5. Decubitus 6. Dryness 7. Scars 8. Lesions 9. Abnormal color 10. Other : 11. Tattoos 12. Body Piercing 13. Skin Tear/ Duoderm/Op-Site Gastrointestinal: □ WNL Bowel sounds □ Good □ Poor □ Recent change Appetite Last BM Date: Color Frequency: □ Yes □ No Laxative use – Type Frequency How long ____ □ Yes □ No Constipation □ Yes □ No Diarrhea □ Yes □ No Nausea □ Yes □ No Vomiting □ Yes □ No Distention □ Yes □ No Hemorrhoids □ Yes □ No Heartburn □ Yes □ No Flatus □ Yes □ No Colostomy □ Yes □ No Ileostomy □ Yes □ No Pain □ Yes □ No Rectal Bleeding □ Yes □ No Weight gain/loss – Reason: Genitourinary: □ WNL Color of urine □ Yes □ No Frequency □ Yes □ No Difficulty starting □ Yes □ No Nocturia □ Yes □ No Foley – Date 1c □ Yes □ No Odor □ Yes □ No Flank pain □ Yes □ No Urgency □ Yes □ No Urostomy □ Yes □ No Burning □ Yes □ No Incontinence □ Yes □ No Hx of calculi □ Yes □ No Itching □ Yes □ No Hx UTI Reproductive: □ WNL FEMALE LMP G □ Yes □ No Menopausal – How long? □ Yes □ No Vaginal discharge □ Yes □ No Hx STD exposure Breast □ Yes □ No Do SBE Monthly? □ Yes □ No Breast feeding □ Yes □ No Dimpling P □ Yes □ No Itching Last PAP □ Yes □ No Birth control □ Yes □ No Hormone replacement □ Yes □ No Dysmenorrhea □ Yes □ No Lesions □ Yes □ No□ Amenorrhea □ Yes □ No Lumps Last Dr. exam □ Yes □ No Nipple discharge □ Yes □ No Symmetry □ Yes □ No Nipple inversion MALE Last prostate exam A Last PSA □ Yes □ No Penile discharge □ Yes □ No Hernias Last mammogram □ Yes □ No Family Hx □ Yes □ No Pain □ Yes □ No Sores □ Yes □ No Testicular lumps Hygiene Breast □ Yes □ No Pain □ Yes □ No Lumps □ Yes □ No Hx STD exposure □ Yes □ No Swelling □ Yes □ No Nipple discharge Hematological: □ WNL □ Yes □ No Bruising □ Yes □ No Anticoagulant use □ Yes □ No Anemia – Hx □ Yes □ No Anemia – Current □ Yes □ No Blood Transfusion – Hx Advanced Directive Does the patient have an Advanced Directive? Advanced Directive form on chart? □ Yes □ Yes Additional information given? □ No □ Yes – Is copy on file? □ No □ Yes – Where? □ No – Explain □ No – Explain Patient Education What does the client (patient/family) say about their learning style? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ According to your textbook, how will you teach a client with this learning style? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ How do you know this client is ready to learn? Pt Statements: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Pt Body Language: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Intrinsic Motivators: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Extrinsic Motivators: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Pt’s Ability to learn (cognitive, physical condition, literacy, etc.): ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ After reviewing all of the above, is your client ready to learn? Why or why not? ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ANALYZE What do you plan on teaching this client? (Learning Goal) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What data did you base this decision on? (Be specific) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What resources will you give your client? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ How will you use these resources based on your client’s learning style? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ R.N. Signature: ___________________________________________________________________________________________ Date: ________________________________________ Time: _______________________________________
The post HEALTH ASSESMENT first appeared on Writeden.