Download diagnostic tests - Trinity Valley Community College

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TRINITY VALLEY COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING
PATIENT ASSESSMENT
Level III
Student's name:
Patient's initials:
Assessment
Age:
Gender:
#1
#2
(check applicable #)
Date of assessment:
Part 1 - Concept: Clinical Judgment - Pathophysiology
Medical Diagnosis (es): (Admitting and other medical diagnoses)
Pathophysiology: Include a referenced pathophysiology of the primary medical diagnosis (es). Include the underlying disease
process, affected organs, signs and symptoms, and complications. Note: If the patient has other diagnoses, a referenced
pathophysiology must be completed on each.
Part 2 - Concept: Clinical Judgment - Assessment
(SUBJECTIVE DATA)
HEALTH HISTORY:
Chief complaint: Use patient's own words.
History of Present Illness (HPI): Include 8 variables of: body location, quantity, quality, chronology, setting, aggravating & alleviating
factors, and associated manifestations.
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Past Medical History (PMH):
1.
2.
How do you rate your health? (check one)
General health and strength: (Describe)
Poor
Fair
Good
Excellent
Health maintenance activities
a)
Last physical examination:
b) Usual source of health care:
c)
Other health maintenance activities:
d) Routine health screening: (BSE, TSE, Mammogram, PSA):
3.
Home Medications: (prescription, nonprescription, vitamins, supplements, herbs, eye drops, birth control method, etc.
Medication
Dosage
Frequency
4.
Allergies: to medications, food, and environment) Describe type of reaction
5.
Any adult illnesses and/or pertinent childhood illnesses?
6.
Surgeries:
7.
Hospitalizations:
8.
Reason
. Immunizations:
Any exposure to contagious illnesses?
9.
Trauma:
10.
Transfusions:
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11.
Family History: (Identify the family member who has specific disease.)
Mother
Father
Grandparents
Siblings
Heart Disease
High Blood Pressure
Stroke
Diabetes
Blood Disorders
Cancer
Sickle Cell Anemia
Arthritis
Osteoporosis
Obesity
Kidney Disease
Tuberculosis
Mental Illness
Seizures
Alcohol/Drug Abuse
12.
Social History
a) Tobacco: (Pack/year history)
k) Travel history
b) Alcohol: (type, amount, frequency)
l) Availability of help
c) Illicit drugs: (type, amount, frequency)
m) Social/recreational activities
d) Marital status/family structure/role in the family
n) Home environment (feels safe at home?)
e) Sexual practices
o) Work environment
f) Living arrangements
p) Spiritual activities
g) Economic status/sources of income
q) Ethnic background
h) Occupational history and military service
r) Stress (perceived)
i) Education
s) Content of an average day: "How does your day go?
j) Mode of transportation
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Part 3 - Concept: Clinical Judgment - Review of Systems
REVIEW OF SYSTEMS
All Subjective
All Objective
PHYSICAL EXAMINATION
All positive responses require further explanation under "comments"
All positive responses require further explanation under "comments"
General
General Appearance of the Patient: (General description,
appearance, gait, speech, facial expression/affect, affect, LOC, sex,
race, orientation, thought processes, body language.)
a) Sleep/rest
b) Activity/exercise
c) Ability to perform self-care activities
d) Nutrition
Grooming:
e) Present weight
Usual weight
Posture:
Expression:
Vital signs:
T:
P:
R:
Pain level:
BP:
Lying:
Which arm?
Sitting:
Height:
Standing:
Weight:
Ideal body weight: (range)
Source:
Integumentary
Concept: Tissue Integrity
Integumentary
Concept: Tissue Integrity
Skin, Hair, and Nails
(using inspection, palpation)
a) Rashes
b) Itching
c) Changes in skin pigmentation
d) Ecchymosis
Skin
Color:
Lesions:
Moisture:
Temperature:
Texture:
Turgor:
Edema:
Braden Scale Assessment:
Bleeding, ecchymosis, vascularity:
e) Any skin lesions (sores, moles, and lumps)
f) Odors, excessive sweating
g) Hair distribution (any changes)
Hair
Color:
Texture:
Distribution:
Scalp lesions:
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h) Changes in nails
i) Amount of time in sun
Nails
Color:
Clubbing:
Comments:
Shape/configuration:
Texture:
j) Use of sunscreen
k) Comments
Describe the normal developmental changes found in this age
patient according to assessment book (referenced):
Head, Eyes, Ears, Nose, Throat (HEENT)
Concept: Sensory Perception
Head, Eyes, Ears, Nose, Throat (HEENT)
Concept: Sensory Perception
(using inspection, palpation)
Head
a) Dizziness
b) Headache
c) Head injuries
Head
Shape:
Contour:
Masses:
Comments:
Symmetry:
Tenderness:
Depressions:
Face
Shape:
Comments:
Symmetry:
d) Comments
Eyes
a) Change in vision
b) Diplopia
c) Glasses
Eyes
Visual acuity: (near, distance)
External eyes: Eyelids:
Lacrimal apparatus:
Drainage:
Extra ocular muscle (EOM) function: 6 cardinal fields of gaze:
d) Floaters
e) Halos
f) Photophobia
g) Drainage
Conjunctiva:
Cornea:
Pupil size: Rt:
Sclera:
Iris:
Lt:
h) Redness
Pupillary light reflex (direct, consensual, accommodation):
i) Itching
Comments:
j) Pain
k) Swelling
l) Last exam
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j) Comments:
Ears
Ears
a) Hearing
Auditory screening (voice-whisper test
b) Hearing aid
d) Tinnitus
External ear:
Color:
Placement:
Deformities:
Inflammation:
e) Pain
Comments:
c) Last hearing test
Size:
Nodules:
Lesions:
f) Itching
g) Discharge
Nose
h) Problems with cerumen
i) How do you clean your ears?
Shape:
Patency of nares: Rt:
Internal inspection:
Sinuses: Frontal:
Maxillary:
Lt:
j) Comments
Comments:
Nose
a) Drainage
Mouth
b) Bleeding
Breath:
Tongue:
Gums:
Palate:
c) Frequent colds
Lips:
Buccal mucosa:
Teeth:
d) Sinus problems
Comments:
e) Obstructions
f) Pain
g) Prior injuries
Throat
h) Comments
Posterior pharynx:
Gag reflex:
Throat
Tonsils:
Comments:
a) Dysphagia
b) Difficulty eating or chewing
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c) Bad breath
Describe the normal developmental changes found in this age
patient according to assessment book (referenced):
d) Cavities
e) Abscesses
f) Mouth ulcers
Neck (using inspection, palpation, and auscultation)
g) Bleeding gums
ROM:
h) Stomatitis
i) Hoarseness
Enlarged lymph nodes: (preauricular, postauricular occipital,
submental, submandibular, anterior cervical chain, posterior
cervical chain tonsilar)
j) Comments
Trachea:
Thyroid:
Carotid bruits:
Neck
Comments:
a) Swollen glands
b) Goiter
c) Stiffness
Describe the normal developmental changes found in this age
patient according to assessment book (referenced):
d) ROM
e) Pain
f) Comments
Breasts, Regional Nodes (inspection, palpation)
Breasts
b) Tenderness
Color:
Contour:
Discharge:
Lymph nodes: Supraclavicular:
Infraclavicular
c) Discharge
Comments
a) Pain
Size:
Vascularity:
Axillary:
d) Lumps
e) Change in size
f) Dimpling
Describe the normal developmental changes found in this age
patient according to assessment book (referenced):
g) Practices BSE?
h) Last Mammogram
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i) Comments
Respiratory System
Concept: Gass Exchange
a) Cough
Productive
Describe
b) Hemoptysis
c) SOB
d) DOE
Respiratory System
Concept: Gas Exchange
(inspection, palpation, auscultation)
Thorax
Shape:
Symmetry of chest wall:
Presence of superficial veins:
Muscles of respiration:
Tenderness to palpation?
Thoracic expansion:
Coast angle:
Angle of ribs:
Tactile Fremitus:
e) Sneezing
f) Wheezing
g) Frequent URI
h) Pneumonia
Respirations
Rate:
Pattern:
Depth:
Audibility:
Patient position:
Mode of breathing:
Cough: productive
nonproductive
Sputum:
Color:
Odor:
Amount:
Consistency:
i) Sleep with head elevated (# of pillows)?
j) Do people tell you that you snore?
Lungs
Breath sounds:
k) Comments
Comments:
Describe the normal developmental changes for this age patient
according to assessment book (referenced):
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Cardiovascular System
Concept: Perfusion
Cardiovascular System
Concept: Perfusion
Heart and Peripheral Vasculature
(inspection, palpation, auscultation)
a) Chest pain
b) Palpitations
c) Easily fatigued
d) Take aspirin (dose)
Precordium
(Indicate the location where heart sounds are auscultated.)
Aortic:
Pulmonic:
Tricuspid:
Mitral:
PMI:
Lifts:
Thrills:
e) Varicose veins
Jugular vein distention:
f) Pain in legs
g) Edema
h) History of rheumatic fever
j) Bruising
k) Comments
Heart Sounds
Rate:
S1:
Murmurs:
Rubs:
S2:
Rhythm:
S3:
S4:
Prosthetic Heart Valves:
Peripheral Vasculature
Capillary refill time (CRT):
Arterial Pulses: (grade on 0-4 scale)
Site
Carotid
Brachial
Radial
Femoral
Post Tibial
Dorsalis pedis
Homan's Sign
Right
Left
Bruit
Hair distribution:
Assistive devices:
Pacemaker: (temporary or permanent):
Hemodynamic monitoring:
Pulse Oximetry:
Telemetry monitoring:
Antiembolic Stocking:
Pneumatic Compression Devices:
Comments
Describe the normal developmental changes for this age patient
according to assessment book (referenced):
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Gastrointestinal System
Concept: Elimination
Gastrointestinal System
Concept: Elimination
Liver, Spleen and Stomach
(inspection, auscultation, palpation)
a) Usual elimination pattern
b) Black tarry stools
c) Indigestion, dyspepsia, reflux
d) Abdominal pain
e) Hemorrhoids
f) Change in appetite
g) Anorexia
h) Nausea
Abdomen
Contour:
Pigmentation & Color:
Scars:
Striae:
Masses, nodules:
Visible peristalsis:
Pulsations:
Intestinal diversions:
Bowel Sounds:
Vascular sounds:
Continence:
Tenderness, pain:
Symmetry:
Umbilicus:
Respiratory movement:
Fluid wave:
Drains, tube:
Urinary diversions:
(aortic bruit) Friction rub:
Rebound tenderness:
i) Vomiting
Rectal
Fissures:
Other:
j) Hematemesis
Hemorrhoids:
k) Diarrhea
Comments
l) Constipation
m) Excessive gas
Describe the normal developmental changes for this age patient
according to the assessment book (referenced):
n) Belching
o) Jaundice
p) Comments
Genitourinary System
Concept: Elimination
Genitourinary
Concept: Elimination
(inspection)
a) Usual elimination pattern
b) Incontinence
c) Dysuria
d) Frequency
Color:
Continent:
Incontinent:
Stress Incontinence:
Catheter
Foley
Clarity:
Odor:
Continous:
Occasional:
Suprapubic
Condom
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e) Hesitancy
f) Urgency
g) Dribbling
h) Nocturia
i) Polyuria
Genitalia (Inspection)
Female (note: may be deferred):
Pubic hair distribution:
Skin color / condtion:
External structures: mons pubis:
Perineum:
Vaginal introitus:
Uretrhral meatus:
Discharge:
Color:
Other:
Vulva:
Clitoris:
CVA tendersness:
Odor:
j) Bed wetting
m) Urethral discharge
Male: (note: may be deferred):
Pubic hair distribution:
Penis:
Scrotum:
Perineum:
Urethral meatus:
Discharge:
Color:
Odor:
Other:
n) History of UTI’s
Comments:
k) Suprapubic pain
l) Change in urine color
o) History of STD’s
p) Comments
Describe the normal developmental changes for this age patient
according to assessment book (referenced):
For females
a) Last menstrual period
b) Hormone replacement therapy
c) Comments
For males
a) Testicular pain
b) Masses
c) Circumcised
d) Comments
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Musculoskeletal System
Concept: Mobility
Musculoskeletal
Concept: Mobility
(inspection, palpation)
a) Muscle weakness
Overall appearance
b) Pain
c) Tenderness
Posture:
Gait:
Mobility:
d) Cramping
e) Atrophy
Muscle strength
Upper extremities (arms, forearms, and hands):
Lower extremities (legs, feet):
f) Joint pain, swelling
g) Backache
Range of Motion
Upper extremities:
Lower extremities:
h) Deformities
i) History of fractures
Deformities
Spine (kyphosis, scoliosis):
Legs:
Feet:
j) Any problems with hends, feet?
k) Use of ambulatory aids
l) Comments
Assistive devices
Crutches:
Cane:
Walker:
Braces:
Splint:
Immobilizer:
Cast:
Skin traction:
Skeletal traction:
External traction:
Comments
Describe the normal developmental changes for this age patient
according to assessment book (referenced)
Neurological
Concept: Cognition, Mood & Affect, Sensory Perception
Neurological
Concept: Cognition, Mood & Affect, Sensory Perception
(inspection, palpation)
a) Headache
b) Change in balance, coordination, loss of movement,
tremors, and involuntary movement
Level of consciousness:
Glascow Coma Scale score:
Orientation
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c) Change in sensory perception / feeling in extremity
numbness, tingling)
d) Change in speech
Sensory Assessment
Touch:
Superficial pain:
Temperature:
Motion & Position sense:
Involuntary movements, tremors:
e) Change in smell
f) Fainting (syncope)
g) Change in memory
h) Loss of consciousness
i) Seizures
Cranial Nerves (Must include “as evidenced by” or AEB)
CN I: Olfactory
CN II: Optic (Assessed with vision screening
CN III: Oculomotor (Assessed with Extra Ocular Muscle (EOM) and
pupillary response:
CN IV: Trochlear (Assessed with Extra Ocular Muscle (EOM):
CN V: Trigeminal:
CN VI: Abducens (Assessed with Extra Ocular Muscle (EOM):
j) Head injury
k) Comments
CN VII: Facial:
CN VIII: Acoustic (Assessed with hearing screening):
CN X: Vagus (Assessed with gag and swallowing):
l) Psychological/Emotional:
1) Irritability-Nervousness
CN XI: Spinal Accessory:
CN XII: Hypoglossal:
2) Tension-Increased stress
3) Difficulty concentrating-Mood changes
4) Depression-Do you want to hurt others?
5) Do you want to hurt yourself?
6) Do you feel safe at home?
7) History of psychiatric care
8) Usual coping mechanisms
9) Defense mechanisms
(Text reference & page number)
10) Comments
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Part 4 – Concept: Human Development
Development Stage (Erickson)
Describe How the Patient in Meeting / Not Meeting the Task. Include specific examples
Concept: Teamwork & Collaboration, Leadership & Management
PHYSICIAN’S ORDERS
Diet (Be specific as to what the Doctor has ordered)
Activity (Be specific as to what the Doctor has ordered)
Treatments (Be specific as to what the Doctor has ordered)
Current medications (including IV and supplemental feeding). List medications, dosage, route, frequency
Medications/IV Fluids
Reason
Dosage
Route
Frequency
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Concept: Health Information Technology Fluid & Electrolyte Balance
DIAGNOSTIC TESTS
Laboratory Date (Include all pertinent lab data)
Test
Reason
Admission Values
Current Values
Normal Values
Radiology /Nuclear Medicine Test
Type of Test
Findings
Other pertinent diagnostic tests
Part 5 – Concept: Patient-Centered Care, Patient Education
Identify teaching and referral needs:
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List all possible problems found during the assessment (subjective & objective)
Must be written in priority order
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Part 6 – Nursing Diagnosis / Concept Maps
From the information obtained during assessment formulate three diagnosis in priority of importance. They must be 2
Physiological & 1 Psychosocial / Knowledge need.
1.
2.
3.
Short Term Goal (STG) for highest priority problem:
Long Term Goal (LTG) for highest priority problem:
Develop a concept map for one of the 3 problems formulated above and attach to this document
Acute Care Assessment - Level 3 Updated 08/2014