Download Client Assessment

LSSC NURSING- CLINICAL DATABASE
Today’s Date:
Student Name:
Patient Initials:
Date and time of
Admission:
Age:
Sex:
Primary Diagnosis:
Secondary Diagnosis:
(Reason for this Admission)
Diabetes
Congestive Heart Failure
Surgical Procedures this Admission:
Living Will:
YES
NO
Power of Attorney:
YES
NO
DNR:
YES
NO
Allergies
Medicines: Food: Latex:
Date
Medications/IV’s
(include dosages & amount)
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Times of
TX
Treatments (Dsg Changes, TED’s,
SCD’s)
Page 1
Chief Complaint on
Admission:
Reason for seeking health care (In patient’s own words) “I broke my hip”
Past Medical
History:
History of Congestive Heart Failure (1985), Diabetes (2000), MI (2004)
Past Surgical
History:
Appendectomy (1960), Total Left Hip Replacement (2004)
Home Medications:
Changes to Home Meds if Applicable:
Continued During Hospital
Stay?
Social History:
Smoker 2 packs x 20 years, quit 2006 or 40 pack year history; no history of
ETOH. Denies illicit drug use. Married with 3 grown children. Lives alone
with wife. Retired from construction in 2003.
Hypertension (Mother, died 1990), Father no known cardiac, DM, Cancer
disease. Died MVA 1990. Brother, 68 Alive and well. Sister 62 with breast
cancer 1998 otherwise no history of cardiac, DM, other cancers.
Family History:
Client Assessment
Vital Signs:
AM
BP
Pulse
Respirations
Temp.
PM
Activity Ordered:
Diet:
Intake:
24 hour
mL
Intake:
POIV-
mL
mL
NU: Sp ‘14 Adopted. REV’d 01/5/15.
% Eaten
Output:
Output:
O2 Sats.
Pain
%@
0/10
RA or L/min
%@
0/10
RA or L/min
Telemetry:
YES
NO
Rhythm:
mL
mL
Page 2
Ht/Wt:
Subjective
HEENT:
Head: Loss of hair, scalp lesions, dandruff
Objective
HEENT:
Head:
Example: No loss of hair, scalp lesions
Eyes: Blurred vision, glasses, contacts,
photophobia, use of protective eyewear, flashing
lights, halos around objects.
Eyes:
Example: Reading glasses for 5 years, last
checked 1 year ago. No symptoms.
Ears: Hearing deficits, hearing aid, pain, vertigo,
ringing in ears, earaches, infection, cerumen (wax
in ears)
Ears:
Example: Hearing good. No tinnitus, vertigo,
infections.
Nose: Discharge, itching, postnasal drip, epistaxis
(nosebleed), change in sense of smell, allergies,
snoring
Nose:
Example: Occasional mild cold. No hay fever,
sinus trouble. No current drainage.
Tongue: Dryness, bad taste, sores
Tongue:
Example: Denies any dryness, bad taste, or sores on
tongue
Throat: Hoarseness, change in voice, frequent
sore throats, dysphagia (difficulty swallowing),
tonsillectomy, adenoidectomy
Throat:
Example: No sore throat, difficulty swallowing.
Cardiovascular: Paroxysmal nocturnal dyspnea
(awakens short of breath), chest pain,
palpitations, syncope (lightheadedness),
orthopnea (state number of pillows used)
Example: No known heart disease or high blood
pressure. No PND, orthopnea, chest pain,
palpitations.
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Cardiovascular:
Rate: Apical
Radial
Rhythm: Regular
Irregular
Pulse Quality/Strength: (0, 1+, 2+, 3+)
Right
Left
Brachial
Femoral
Popliteal
Pedal
Post-Tibial
Carotids
Carotid Bruit: Yes___No___R____L____
S-1 S-2
Murmurs:
Capillary Refill: R seconds L seconds
PMI Location:
Page 3
Peripheral-Vascular:
Legs: Color R
(Pink, Pale, Cyanotic) L
Temperature: R
(Cool, Warm, Hot)
L
Trace:
R
R
L
L
(1+, 2+, 3+, 4+) Present Absent Present Absent
Pedal Edema
Pitting Edema
Leg Edema above ankle (Describe locations, amount,
bilateral/unilateral):
Respiratory: Dyspnea on exertion, shortness of
breath, sputum, cough, hemoptysis (coughing up
blood)
Example: No cough, wheezing, shortness of
breath.
Lesions: R
L
Describe:
Respiratory:
Rate: /min
Ease/Effort: Non-labored
Labored
Depth: Shallow
Normal
Deep
Character: Quiet/Silent
Noisy
Chest Expansion: Symmetrical
Asymmetrical
Intercostals: Bulging
Retraction
Normal
Breath Sounds:
Clear
Wheezes
Ronchi
Crackles
Anterior:
Posterior:
R-Lateral:
L-Lateral:
Cough: None
Non-Productive
Productive
Describe: N/A
Odor:
Color:
Bilaterally
Gastrointestinal: Last Bowel Movement:
Describe consistency, color, and amount:
Genitourinary: Change in urine color, pain on
urination, hesitancy, urgency, frequency, nocturia
(getting up at night to urinate), polyuria (voiding
many times), loss in force of stream, incontinence,
urinary retention
Gastrointestinal:
Oral Mucosa: Pink
Pale
Dry
Moist
Intact
Lesions
Dentures: None
Upper
Lower
Partial Plate
Teeth Condition:
None
Abdominal Contour: Flat
Rounded
Scaphoid
Protuberant
Bowel Sounds: Normoactive
Hypoactive
Hyperactive
Location: RLQ
RUQ
LLQ
LUQ
Abdominal Aortic Bruit: Present
Not Present
Illiacs Bruit: (R) Present
Not Present
(L) Present
Not Present
Renal Bruit: (R) Present
Not Present
(L) Present
Not Present
Abdomen: Soft
Firm
Tense
Distended
Tender
Location:
Presence of surgical incision:
Umbilicus:
Genitourinary:
Urine Output: YES
NO
Color: Amber
Light
Dark Amber
Bloody
Blood Tinged
Clear
Sediment
Odor: YES
NO
Describe:
Example: No frequency, dysuria, hematuria, or
recent flank pain; nocturia x1, large volume.
Occasionally loses some urine when coughs hard.
.
Musculoskeletal: Joint stiffness, muscle pain,
cramps, back pain, limitation of movement,
redness, swelling, weakness.
Musculoskeletal:
Movement/Gait: Erect
Weak
Flacid
Change in appetite, nausea, vomiting, diarrhea,
constipation, usual bowel habits, rectal bleeding,
melena (blood in stool), hematemesis (spitting up
blood), change in stool color, heartburn,
hemorrhoids
Example: Appetite good; no nausea, vomiting,
indigestion. Bowel movement about once daily,
though sometimes has hard stools for 2-3 days
when especially tense; no diarrhea or bleeding.
.
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Steady
Smooth and Coordinated
Page 4
Example: Mild, aching, low-back pain, often after
a long day’s work; no radiation down the legs;
used to do back exercises but not now. No other
joint pain
Integumentary: Rashes, lumps, sores, itching,
dryness, color changes
Example: No rashes or other changes
Neurological: Headache, head injury, dizziness,
lightheadedness
Example: No history of head injury, dizziness,
has occasional “stress” headaches relieved with
acetaminophen x 2 tabs.
Psychosocial (Erikson):
Irritability, nervousness, tension, increased stress,
difficulty concentrating, mood changes, suicidal
thoughts, depression, anxiety, sleep disturbances.
Strength: (5+, 4+. 3+, 2+, 1+, 0) =
Able to turn self
Bears own weight
ROM: Full
Limited
Describe:
Assistive Devices: None
Walker
Cane
Crutches
Wheelchair
Integumentary:
Color: Pink
Pale
Cyanotic
Jaundiced
Temperature: Cold
Cool
Warm
Hot
Condition: Dry
Moist
Clammy
Diaphoretic
Integrity: Intact
Rash
Wound
Describe:
Turgor: Immediate
Remains Peaked
Taut
Neurological:
Response: Alert
Lethargic
Stuporous
Comatose
Orientation: Person
Place
Time
Situation
PERRLA: Right
Left
Hand Grips: Weak
Strong
Bilaterally
Mood: Appropriate
Not Appropriate
Attitude/Behavior: Cooperative
Hostile
Combative
Withdrawn
Psychosocial (Erikson):
Example: No history of depression or treatment
for psychiatric disorders.
Lab Values:
Na
HGB
BUN
Glucose
PLT
WBC
HCT
CCC
CCC
CCC
CCX
CC
Cl
\
K
HCO
CR
jhjhjhjkj
1. Lab Values Interpretation.
2. Prioritize Actual problems (Problem + related to AEB).
3. List Interventions that you provided this shift for the above problems.
4. List teaching given to this patient (written, video, demonstration).
5. List diagnostic test.
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Page 5
Critical Thinking Assignment:
Answer the questions below based on your above assessment and data collection from your
patient.
1. What are you alert for today with your patient?
2. What are the important assessments to make?
3. What complications may occur? What could go wrong?
4. What interventions will prevent complications?
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Page 6
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Page 7