Download Assessment Form

CENTRAL TEXAS COLLEGE
STUDENT NAME:
DATE:
DEPARTMENT OF NURSING
ASSESSMENT FORM: Spring 2006
VS T.
Allergies:
HR.(Apical)
(Radial)
Client’s Number
RR.
BP.
Smoking History/ Educational Material provided:
Hospitalizations
Ht.
Education/School Grade
Siblings-Age & Sex
PT. Init.
Wt.
BMI:_______ PO2________
Immunization status: Pneumvox date:
Development/Human Needs Level:
Influenza/date:
Family Support/Extended Family: __________
Cultural/Ethnic Considerations /Educational Needs:
Religion/ Spiritual Choice:
Discharge Planning Needs:
_
__________
Advanced Directive/location:
Primary / Secondary Diagnoses:
Medications:
INSTRUCTIONS:
NORMAL FINDINGS
If patient exhibits the findings listed below, check that
line. If a finding is abnormal or you are not able to
assess for one of the findings, write an * in the box and
explain on a separate sheet of paper. Please circle Y for
Yes or N for No. When appropriate check Yes or No.
NEUROLOGICAL ASSESSMENT
Disorientated
Alert, responsive to stimuli. Behavior appropriate
for age/development stage. Speech clear and
appropriate for age. Moves all extremities.
Fontanel (if applicable) soft & flat
Y N PERRLA
FOCUS ASSESSMENT INDICATED:
ABNORMAL FINDING(S)/
PRE-EXISTING CONDITIONS
Check and/or describe abnormal finding(s)/
pre-existing conditions. If the information asks
you to specify (describe location, grade, etc...)
Yes
No
Y N Paresthesia
Y N Upper Extremities (Equal Strength Bilaterally)
Person
Place
Situation
Lethargic
Drowsy
Angry
Un-communicative
High-pitched cry
Seizures
Flat Affect
Sunken Fontanel
Bulging Fontanel
Aphrasia
Primitive Reflexes
Other:
Time
Posturing
Comatose
Anxious
Irritable
Paralyzed
Unresponsive
Dysphagia
Aphasia
Aphonia
Y N Lower Extremities (Equal Strength Bilaterally)
EYES, EARS, NOSE, MOUTH, THROAT
ASSESSMENT
No evidence of non-compensated visual or hearing loss.
Dentition normal for age. No redness or swelling to
throat. Nares patent. No evidence of bleeding or
discharge from nose. Denies pain. Mucous Membranes
Moist and Intact
FOCUS ASSESSMENT INDICATE:
Y N Palpable Nodes
Y N Dentures U
Y N Hearing Aid
Y N Glasses
Y N Prosthesis
Rt.
No
L
Rt.
Bifocals
Yes
Lt.
Contact Lens
Rt.
Lt. (Specify Upper
Lt.
Lower
INTEGUMENTARY ASSESSMENT
Skin color normal, warm, and dry. Normal hair
distribution and texture. Nails clean without
cracking or splitting. No Lesions Noted. Skin
Intact.
FOCUS ASSESSMENT INDICATED:
Y
IV
Yes
N
Yes
No
Fragile Skin
No
Gauge
Location
Central Line:
Yes
No
Location
PICC Line:
Yes
No
Location
Porta Cath:
Yes
No
Location
NURSING DIAGNOSIS
Check or list diagnosis appropriate for abnormal
finding(s). Make a check mark in the appropriate
box. Write a R/T statement that corresponds to
your abnormal findings. Identify the functional
health pattern(s) that correlates to your diagnosis.
Growth and Development, Delayed
Sensory perception, Disturbed
Autonomic dysreflexia, Risk for
Confusion: Acute
Chronic
Intracranial adaptive capacity, Decreased
Transfer ability, Impaired
Thermoregulation, Ineffective
Communication, Impaired verbal
Communication, Readiness for enhanced
Memory, Impaired
Mobility, Impaired bed
Mobility, Impaired physical
Mobility, impaired wheelchair
FHP:
Abnormal Conjunctiva
Swelling
Visual Impairment
Cleft Lip
Hearing Impairment
Cleft Palate
Bleeding Gums
Cataracts
Dental Lesions
Rhinorrhea
Tubes in Ears
Decreased Tearing
Lesions (Specify:
Nodules: (Specify
Trach (Size:
)
Other:
Pale
Cold
Hot
Turgor
Itching
Rashes
Scabies
Fragile
Hives
Wounds
Cysts
Tumors
Lice
Ecchymosis
Other:
Sensory perception, Disturbed
(Specify):
Oral Mucous Membrane, Impaired
Pain: Acute Chronic (Specify Where
and Rate on a Pain Scale)
Dentition, Impaired
Other:
)
)
FHP:
Infection, Risk for
Flushed
Diaphoretic
Flaky
Redness
Skin Integrity, impaired
Petechiae
Body Temperature, Risk for imbalanced
Decubitus
Hyperthermia
Alopecia
Hypothermia
Jaundiced
Allergy Response, Latex
Drainage
Allergy Response, Risk for latex
Other
Skin Integrity, Risk for impaired
FHP:
ABNORMAL FINDING(S)/
PRE-EXISTING CONDITIONS
NORMAL FINDINGS
CARDIOVASCULAR ASSESSMENT
NURSING DIAGNOSIS
Cyanosis
Pale
Mottled
Capillary refill time >3 seconds
Skin warm and dry, color normal for ethnicity.
Radial (Apical) heart rhythm regular. Blood pressure
within normal limits for age. No peripheral edema.
Mucous membranes pink.
Tissue Perfusion, Ineffective
Tissue Integrity, Impaired
Distal Pulses Absent:
Carotid Pulse
Rt.
Lt
Temporal
Rt
Lt
Cardiac Output, Decreased
Fluid Volume, Excess
Y
N
Capillary refill time < 2-3 seconds
FOCUS ASSESSMENT INDICATED:
Yes
No
Upper Extremities
Radial
Rt.
Lt.
Brachial
Rt
Lt
Fluid Volume, Deficit
Fluid Volume, Risk for Deficit
Y N
Y N
Y N
Carotid pulses regular and symmetrical
Temporal pulses regular & symmetrical
Peripheral pulses equal bilaterally:
Rate:
Radial
Rt.
Lt.
Brachial
Rt.
Lt.
Lower Extremities:
Femoral
Rt
Lt.
Tibial
Rt.
Lt.
Dorsalis Pedis Rt
Lt
N
Fluid Volume, Readiness for enhanced
Hypotensive
Hypertensive
Diaphoretic
Heart Sounds
S3
S4
Tachycardia
Bradycardia
Jugular Vein Distention Rt. Lt
Bilaterally
Femoral
Rt.
Lt.
Dorsalis Pedis
Rt.
Lt.
Popliteal
Rt.
Lt.
Posterior Tibialis
Rt.
Lt.
Y
Fluid Volume, Risk for imbalanced
Pain: Acute Chronic (Specify Where and
Rate on the Pain Scale)
Arrhythmia:(Specify)
Chest pain
Edema:(
Other
Grade/Amt)
Location:
FHP:
Other:
RESPIRATORY ASSESSMENT
Respirations unlabored, with an at rest rate normal for
age. No cough or stridor. Bilateral breath sounds clear
throughout anterior and posterior lung fields. No
abnormal sounds. Mucous membranes pink. TCDB as
applicable.
FOCUS ASSESSMENT INDICATED:
Yes
Y N
Use of accessory muscles
Y N
Nasal flaring
Y N
Grunting respirations
Oxygen Saturation
No
GASTROINTESTINAL ASSESSMENT
Abdomen soft, non-distended with active bowel sounds.
States regular bowel movements. Denies pain.
Bowel Sounds
Indicate in each
quadrant (+) for
bowel sounds present
and (-) for bowel
sounds absent.
FOCUS ASSESSMENT INDICATED:
Yes
Y N Swallowing without coughing or choking)
Y N Abdominal Tenderness
No
ABDOMINAL GIRTH (If Applicable)
GENITOURINARY/GYNECOLOGICAL
ASSESSMENT
Voiding without difficulty. Denies frequency or burning
with urination. Denies changes in appearance, volume,
or odor of urine. Genitalia appropriate for age and sex.
FOCUS ASSESSMENT INDICATED:
Y
N
Yes
Bladder Distended
Male: Last Prostate Exam
Last Testicular Exam
Female: LMP:
Last Breast Exam
Last Pap Smear:
No
Dyspnea
Restless
Orthopnea
Clubbing
Tachypnea
Cyanosis
Apnea
Stridor
Crackles
Fermitus
Nasal Flaring
Wheezing
Home Nebs.
Rhonchi
Home Apnea Monitor
Cheyne stokes
Home O2 Therapy
Cough
Prod.
Unproductive.
Friction Rub
Diminished Br. Sounds:
Rt.
Lt.
Retractions
Kussmal Respirations
Other:
Absent Bowel Sounds
Fistula
Rigid Abdomen
Diarrhea
Umbilical Hernia
Constipation
Distended Abdomen
Dysphasia
Hypoactive Bowel Sounds
Vomiting
Depressed Fontanel
Hemorrhoids
Hyperactive Bowel Sounds
Ascites: (
Pain:
Tenderness:
Ostomy:
Tubes:
Malodorous
Incontinence
Urinary Retention
Supra Pubic Catheter
Hypospadias
Frequency:
Self Cath
Ambiguous Genitalia
Oliguria
Dysuria
Anuria
Prostate Enlargement
STD’S
Testicular Mass
Hematuria
Foley Catheter
Enuresis
Other:
Breathing Pattern, Ineffective
Airway Clearance, Ineffective
Gas Exchange, Impaired
Aspiration, Risk for
Other:
FHP:
Nutrition: Less than Body Requirements
Imbalanced
Nutrition: More than Body Reqiore,emts
Imbalanced
Constipation Diarrhea Nausea
Bowel Incontinence
Aspiration, Risk f or
Swallowing, Impaired
Pain: Acute Chronic (Specify Where
and Rate on the Pain Scale)
)
Nutrition: Readiness for enhanced
FHP:
Hernia
Hydrocele
Ostomy
Urinary Elimination, Impaired
Infection, Risk For
Urinary Elimination, Readiness for enhanced
Urinary Retention
Incontinence, Functional urinary
Incontinence, Reflex urinary
Incontinence, Stress urinary
Incontinence, Total urinary
Incontinence, Urge urinary
Incontinence, Risk for urge urinary
Pain: Acute
Chronic (Specify Where
and Rate On a Pain Scale)
Nocturia
Other:
FHP
ABNORMAL FINDINGS(S)/
PRE-EXISTING CONDITIONS
NORMAL FINDINGS
MUSCULOSKELETAL ASSESSMENT
Spasticity (Specify Where)
Y
N
Joint swelling
Joint Swelling (Specify)
Y
N
Joint tenderness
Prosthesis: (Specify Where)
FOCUS ASSESSMENT INDICATED
NURSING DIAGNOSIS
Yes
No
Impaired Physical Mobility
Mobility, Impaired physical
Mobility, Impaired bed
Injury, Risk For (Specify)
Walking, Impaired
Body Image , Disturbed
Wandering
Falls, Risk For
Transfer Ability Impaired
Pain: Acute Chronic
(Specify Where and Rate on a Pain Scale)
Tenderness(Specify Where)
Limitation of Motion (Specify)
Y
N
Full ROM for all joints
Weakness
Assistive Devices: (Specify)
Y N
Muscle Weakness
Y N
Gait, balance, and ambulation
normal for age
Other:
Other: (Specify)
FHP
SAFETY ASSESSMENT:
No Safety Risk: Patient adult, active & alert
Y
N Age Related (Specify)
Y
N
Vision
 LOC
Hx. Of Seizures
Sedation
Confusion
Injury, Risk for
Environmental interpretation syndrome,
Impaired
Falls, Risk for
Altered Thought Processes
Energy Field, Distrubed
Impaired Memory
Perceptual, Alterations In: (Specify)
Sensory perception, Disturbed
Risk Taking Behaviors:
Y
Medication Related: (Specify)
N Developmentally Related: (Specify)
Y N History of Falls
Y N History of Syncope
Y N Unsteady Gait
Other:
Other:
FHP:
EDUCATIONAL ASSESSMENT
Teaching :
Patient
SO
Procedures
Medications
Disease Processes
Other:
Parent
Other
Substance Use:
Tobacco Use Type:
Knowledge, Deficit ( Specify)
Amount/Frequency
Therapeutic regimen management,
Ineffective
Knowledge, Readiness for enhanced
Family
Alcohol Use Type:
Amount/Frequency:
REFERRALS
Other:
Time/Date Last Drink
Y N Referral Indicated
Rec. Drug Use Type:
Type of Referral Needed:
Type Of Referral (Specify)
Last Use:
FHP:
PSYCHOSOCIAL ASSESSMENT
Oriented x4. Appears stated age. Hygiene, grooming
adequate. Dress appropriate for age & situation.
Movement & posture normal for age & development.
Maintains eye contact. Speech appropriate in rate, tone
and volume. Attitude friendly, cooperative. Mood
euthymic. Affect congruent with mood; intensity,
mobility and range of affect appropriate to situation.
Thought processes and thought content normal. Able to
concentrate. Judgment & insight good. Recent and
remote memory intact. No vegetative sign. No
suicidal/homicidal ideation, intent, plans.
Family/support system intact.
FOCUS ASSESSMENT INDICATED:
SADPERSONS
Yes
No
ASE
GROWTH & DEVELOPMENT ASSESSMENT
The client is working through the age appropriate
development task. Height and weight is between
the 10 and 90 percentile. Meets developmental
milestones.
FOCUS ASSESSMENT INDICATED
Yes
No
Appearance:
(Age, Hygiene, Attire)
Movement/Posture
Insight
Eye Contact
Memory
Speech
Mood
Attitude
Behavior
Vegetative Signs
Judgment
Suicidal
Homicidal
Cognitive Disturbance
Perceptual Disturbance
Concentration
Psych. History
Family History
Affect
Other:
Low Weight
Obese
Short Stature
Gigantism
< 10 Percentile (Ht Wt. HC)
> 90 Percentile (Ht Wt. HC)
Developmental Delay (Specify)
Other:
Anxiety (Level/s)
Coping, Ineffective
Fear
Grieving, Anticipatory
Grieving, Dysfunctional
Hopelessness
Powerlessness :
Protection, Ineffective
Management of Therapeutic
Regimen, Ineffective
Risk for Violence
Self
Suicide, Risk for
Thought processes, Disturbed
Other: (Specify)
FHP:
Growth & Development, Delayed
(Specify):
Growth, Risk for disproportionate
Nutrition < Body Requirements
Nutrition > Body Requirements
Nutrition, Readiness for enhanced
Coping Defensive
Conflict Parental Role
Caregiver role strain
Caregiver role strain, Risk for
FHP:
Others
ABNORMAL FINDING(S)/
PRE-EXISTING CONDITIONS
NORMAL FINDINGS
CARDIOVASCULAR ASSESSMENT
Cyanosis
Pale
Mottled
Capillary refill time >3 seconds
Skin warm and dry, color normal for ethnicity.
Radial (Apical) heart rhythm regular. Blood pressure
within normal limits for age. No peripheral edema.
Mucous membranes pink.
NURSING DIAGNOSIS
Tissue Perfusion, Ineffective
Tissue Integrity, Impaired
Distal Pulses Absent:
Carotid Pulse
Rt.
Lt
Temporal
Rt
Lt
Cardiac Output, Decreased
Fluid Volume, Excess
Y
N
Capillary refill time < 2-3 seconds
FOCUS ASSESSMENT INDICATED:
Yes
No
Upper Extremities
Radial
Rt.
Lt.
Brachial
Rt
Lt
Fluid Volume, Deficit
Fluid Volume, Risk for Deficit
Y N
Y N
Y N
Carotid pulses regular and symmetrical
Temporal pulses regular & symmetrical
Peripheral pulses equal bilaterally:
Rate:
Radial
Rt.
Lt.
Brachial
Rt.
Lt.
Lower Extremities:
Femoral
Rt
Lt.
Tibial
Rt.
Lt.
Dorsalis Pedis Rt
Lt
N
Fluid Volume, Readiness for enhanced
Hypotensive
Hypertensive
Diaphoretic
Heart Sounds
S3
S4
Tachycardia
Bradycardia
Jugular Vein Distention Rt. Lt
Bilaterally
Femoral
Rt.
Lt.
Dorsalis Pedis
Rt.
Lt.
Popliteal
Rt.
Lt.
Posterior Tibialis
Rt.
Lt.
Y
Fluid Volume, Risk for imbalanced
Pain: Acute Chronic (Specify Where and
Rate on the Pain Scale)
Arrhythmia:(Specify)
Chest pain
Edema:(
Other
Grade/Amt)
Location:
FHP:
Other:
RESPIRATORY ASSESSMENT
Respirations unlabored, with an at rest rate normal for
age. No cough or stridor. Bilateral breath sounds clear
throughout anterior and posterior lung fields. No
abnormal sounds. Mucous membranes pink. TCDB as
applicable.
FOCUS ASSESSMENT INDICATED:
Yes
Y N
Use of accessory muscles
Y N
Nasal flaring
Y N
Grunting respirations
Oxygen Saturation
No
GASTROINTESTINAL ASSESSMENT
Abdomen soft, non-distended with active bowel sounds.
States regular bowel movements. Denies pain.
Bowel Sounds
Indicate in each
quadrant (+) for
bowel sounds present
and (-) for bowel
sounds absent.
FOCUS ASSESSMENT INDICATED:
Yes
Y N Swallowing without coughing or choking)
Y N Abdominal Tenderness
No
ABDOMINAL GIRTH (If Applicable)
GENITOURINARY/GYNECOLOGICAL
ASSESSMENT
Voiding without difficulty. Denies frequency or burning
with urination. Denies changes in appearance, volume,
or odor of urine. Genitalia appropriate for age and sex.
FOCUS ASSESSMENT INDICATED:
Y
N
Yes
Bladder Distended
Male: Last Prostate Exam
Last Testicular Exam
Female: LMP:
Last Breast Exam
Last Pap Smear:
No
Dyspnea
Restless
Orthopnea
Clubbing
Tachypnea
Cyanosis
Apnea
Stridor
Crackles
Fermitus
Nasal Flaring
Wheezing
Home Nebs.
Rhonchi
Home Apnea Monitor
Cheyne stokes
Home O2 Therapy
Cough
Prod.
Unproductive.
Friction Rub
Diminished Br. Sounds:
Rt.
Lt.
Retractions
Kussmal Respirations
Other:
Absent Bowel Sounds
Fistula
Rigid Abdomen
Diarrhea
Umbilical Hernia
Constipation
Distended Abdomen
Dysphasia
Hypoactive Bowel Sounds
Vomiting
Depressed Fontanel
Hemorrhoids
Hyperactive Bowel Sounds
Ascites: (
Pain:
Tenderness:
Ostomy:
Tubes:
Malodorous
Incontinence
Urinary Retention
Supra Pubic Catheter
Hypospadias
Frequency:
Self Cath
Ambiguous Genitalia
Oliguria
Dysuria
Anuria
Prostate Enlargement
STD’S
Testicular Mass
Hematuria
Foley Catheter
Enuresis
Other:
Breathing Pattern, Ineffective
Airway Clearance, Ineffective
Gas Exchange, Impaired
Aspiration, Risk for
Other:
FHP:
Nutrition: Less than Body Requirements
Imbalanced
Nutrition: More than Body Reqiore,emts
Imbalanced
Constipation Diarrhea Nausea
Bowel Incontinence
Aspiration, Risk f or
Swallowing, Impaired
Pain: Acute Chronic (Specify Where
and Rate on the Pain Scale)
)
Hernia
Hydrocele
Ostomy
Nocturia
Nutrition: Readiness for enhanced
FHP:
Urinary Elimination, Impaired
Infection, Risk For
Urinary Elimination, Readiness for enhanced
Urinary Retention
Incontinence, Functional urinary
Incontinence, Reflex urinary
Incontinence, Stress urinary
Incontinence, Total urinary
Incontinence, Urge urinary
Incontinence, Risk for urge urinary
Pain: Acute
Chronic (Specify Where
and Rate On a Pain Scale)
Other:
FHP
ABNORMAL FINDINGS(S)/
PRE-EXISTING CONDITIONS
NORMAL FINDINGS
MUSCULOSKELETAL ASSESSMENT
Spasticity (Specify Where)
Y
N
Joint swelling
Joint Swelling (Specify)
Y
N
Joint tenderness
Prosthesis: (Specify Where)
FOCUS ASSESSMENT INDICATED
NURSING DIAGNOSIS
Yes
No
Impaired Physical Mobility
Mobility, Impaired physical
Mobility, Impaired bed
Injury, Risk For (Specify)
Walking, Impaired
Body Image , Disturbed
Wandering
Falls, Risk For
Transfer Ability Impaired
Pain: Acute Chronic
(Specify Where and Rate on a Pain Scale)
Tenderness(Specify Where)
Limitation of Motion (Specify)
Y
N
Full ROM for all joints
Weakness
Assistive Devices: (Specify)
Y N
Muscle Weakness
Y N
Gait, balance, and ambulation
normal for age
Other:
Other: (Specify)
FHP
SAFETY ASSESSMENT:
No Safety Risk: Patient adult, active & alert
Y
N Age Related (Specify)
Y
N
Vision
 LOC
Hx. Of Seizures
Sedation
Confusion
Injury, Risk for
Environmental interpretation syndrome,
Impaired
Falls, Risk for
Altered Thought Processes
Energy Field, Distrubed
Impaired Memory
Perceptual, Alterations In: (Specify)
Sensory perception, Disturbed
Risk Taking Behaviors:
Y
Medication Related: (Specify)
N Developmentally Related: (Specify)
Y N History of Falls
Y N History of Syncope
Y N Unsteady Gait
Other:
Other:
FHP:
EDUCATIONAL ASSESSMENT
Teaching :
Patient
SO
Procedures
Medications
Disease Processes
Other:
Parent
Other
Substance Use:
Tobacco Use Type:
Knowledge, Deficit ( Specify)
Amount/Frequency
Therapeutic regimen management,
Ineffective
Knowledge, Readiness for enhanced
Family
Alcohol Use Type:
Amount/Frequency:
REFERRALS
Other:
Time/Date Last Drink
Y N Referral Indicated
Rec. Drug Use Type:
Type of Referral Needed:
Type Of Referral (Specify)
Last Use:
FHP:
PSYCHOSOCIAL ASSESSMENT
Oriented x4. Appears stated age. Hygiene, grooming
adequate. Dress appropriate for age & situation.
Movement & posture normal for age & development.
Maintains eye contact. Speech appropriate in rate, tone
and volume. Attitude friendly, cooperative. Mood
euthymic. Affect congruent with mood; intensity,
mobility and range of affect appropriate to situation.
Thought processes and thought content normal. Able to
concentrate. Judgment & insight good. Recent and
remote memory intact. No vegetative sign. No
suicidal/homicidal ideation, intent, plans.
Family/support system intact.
FOCUS ASSESSMENT INDICATED:
SADPERSONS
Yes
No
ASE
GROWTH & DEVELOPMENT ASSESSMENT
The client is working through the age appropriate
development task. Height and weight is between
the 10 and 90 percentile. Meets developmental
milestones.
FOCUS ASSESSMENT INDICATED
Yes
No
Appearance:
(Age, Hygiene, Attire)
Movement/Posture
Insight
Eye Contact
Memory
Speech
Mood
Attitude
Behavior
Vegetative Signs
Judgment
Suicidal
Homicidal
Cognitive Disturbance
Perceptual Disturbance
Concentration
Psych. History
Family History
Affect
Other:
Low Weight
Obese
Short Stature
Gigantism
< 10 Percentile (Ht Wt. HC)
> 90 Percentile (Ht Wt. HC)
Developmental Delay (Specify)
Other:
Anxiety (Level/s)
Coping, Ineffective
Fear
Grieving, Anticipatory
Grieving, Dysfunctional
Hopelessness
Powerlessness :
Protection, Ineffective
Management of Therapeutic
Regimen, Ineffective
Risk for Violence
Self
Suicide, Risk for
Thought processes, Disturbed
Other: (Specify)
FHP:
Growth & Development, Delayed
(Specify):
Growth, Risk for disproportionate
Nutrition < Body Requirements
Nutrition > Body Requirements
Nutrition, Readiness for enhanced
Coping Defensive
Conflict Parental Role
Caregiver role strain
Caregiver role strain, Risk for
FHP:
Others