Nursing Assessment Form Gordon PDF

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Download Nursing Assessment Form Gordon PDF

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Nursing Assessment Form Using Modified Gordon’s Functional Health Patterns STAPLE ALL SHEETS TOGETHER AND EITHER PRINT OR TYPE LEGIBLE ON ALL FORMS Student Name: _____________________________ Dates of Care: ___________ Instructor: _______________________ Patient Initials: _________ Male__ / Female___ Patient Age: ________ Facility: _____________________________ General Information: Chief Complaint: _________________________________________________________________ Has patient been in the hospital or other health facility in past six months? Yes / No If yes to above, What was the nature of the problem? _______________________________________________________________ What Erikson’s Development Stage is patient in right now?___________________________________________________________ Is patient meeting their tasks in this stage? Yes / No Why or why not? __________________________________________________ Vital Signs: Temperature: ________ Source: _________ Pulse: _________ Source: ________ Respirations: _________ Source: ________ BP: __________ Lying / Sitting / Standing Source: _________ Oxygen Saturation: _________ Room Air / Supplemental Oxygen Height: _______ Actual / Stated Weight: ________ Actual / Stated Allergies: (Include those to medications, foods, environment, etc) Source Reaction _____________________________________________ ________________________________________________ _____________________________________________ _________________________________________________ _____________________________________________ _________________________________________________ Functional Health Patterns Health Perception/ Health Maintenance 1.

2.

3. 4. 5.

6. 7. 8. 9. 10. 11. 12. 13. 14.

15. 16.

Does the patient have any health issues they would like to improve? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _ Preexisting conditions, previous surgeries or procedures? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Has the patient been exposed to any communicable diseases within the past year? Yes / No If yes to above, explain: _________________________________________________________________________________ Medications taken at home (include prescribed, OTC, herbals or natural remedies, and/or vitamin or mineral supplements): Name (generic if possible) Dose/Frequency/Route Reason patient is taking _________________________ __________________ ___________________________________ _________________________ __________________ __________________________________ _________________________ __________________ __________________________________ _________________________ __________________ ___________________________________ _________________________ __________________ ____________________________________ _________________________ __________________ ____________________________________ _________________________ __________________ ____________________________________ _________________________ __________________ ____________________________________ Does the patient have any problems from their medications? Yes _____ / No______ If yes to above, explain: ____________________________________________________________________________ Does the patient have any problems paying for their medications, supplies, or services? Yes ____ / No ______ If yes to above, explain: _____________________________________________________________________________ Has patient ever had a blood product transfusion? Yes / No If yes to above, what type of blood product? _________________________ If yes to #10, did the patient experience a blood reaction with transfusion? Yes / No If yes to above, explain: _____________________________________________________________________________ Please check all screenings the patient has performed or had performed in the past year: ___ Breast Exam ___ Dental Exam ___ Glaucoma ___ Mammogram ___ Pap Smear ___ Pelvic Exam ___ Prostate Check ___ Rectal Check ___ Testicular Check ___ Vision Check Please check all immunizations the patient has had in the past year: ___ Flu ___ Pneumonia ___ Tetanus ___ Other Does the patient smoke? Yes / No If yes, how many pack-years? ________

Does patient use other tobacco or nicotine products? Yes / No If yes, describe product and pattern of use: _____________________ 17. Does the patient drink alcohol? Yes / No If yes, describe specifically the pattern of use: _____________________ _____________________________________________________________________When was last drink? __________ 18. Does patient use illegal drugs or prescription drugs in a way that is not prescribed for them? Yes / No If yes, describe specifically the pattern of use: _______________________________When was last use? ____________ Nursing Diagnoses MARK APPRORIATE DXS ___ Risk for Falls ___ Ineffective Health Maintenance ___ Health-Seeking Behaviors ___ Readiness for Enhanced Immunization Status ___ Risk for Infection ___ Risk for Injury ___ Noncompliance ___ Readiness for Enhanced Self-Care ___ Effective Therapeutic Regimen Management ___ Ineffective Therapeutic Regimen Management ___ Ineffective Family Therapeutic Regimen Mgnt Other: ___________________________

Nutritional/Metabolic Pattern Does the patient follow a special diet? Yes / No If yes, explain: ________________________________________ When was the last time the patient ate? ____________________ Has the patient been asked to increase or restrict fluid intake? Yes / No If yes, explain: _______________________ Dentures? ___ None ___ Uppers ___ Lowers ___ Partial Plate If patient has dentures, do they fit well? Yes / No If no, explain: ___________________________________ Appetite? ___ Normal ___ Increased ___ Decreased ___ Unable to Assess Does the patient have difficulty with: ___ None ___ Chewing ___ Choking ___ Following Prescribed Diet ___ Smelling ___ Swallowing ___ Tasting If any difficulty, explain: _____________________________ 8. Does the patient have: ___ None ___ Indigestion ___ Mouth Soreness ___ Nausea ___ Vomiting ___ Persistent Fever ___ Weight Loss/Gain (how much over how long? _______________) 9. Skin/Mucosa: color: __ Cyanotic ___ Dusky ___ Flushed __ Jaundiced ___ Mottled ___ Pale ___ Pink Temperature: ___ Hot ___ Warm ___ Cool ___ Cold Moisture: ___ Dry ___ Clammy ___ Diaphoretic Turgor: ___ Elastic ___ Inelastic ___ Tenting Edema: ___ None ___ Generalized ___ Localized (location/s:__________________________________________) If patient has edema, grade each location 1-4___________________________________________________________ 10. Oral Mucous Membranes: ___ Dry ___ Intact ___ Moist ___ Lesions (if yes, describe: _____________________) 11. Wounds/Drains/Tubes/Catheters/Dressings: ___ None If yes, describe: _____________________________________ ________________________________________________________________________________________________ 12. Braden Skin Risk Assessment Score: ___ 15-16 Low Risk ___ 13-14 Moderate Risk ___ 12 or < Severe Risk 13. Comments:__________________________________________________________________________________________ 1. 2. 3. 4. 5. 6. 7.

Nursing Diagnoses MARK APPRORIATE DXS ___ Risk for Aspiration ___ Risk for Imbalanced Body Temperature ___ Impaired Dentition ___ Failure to Thrive (Adult)___ Deficient Fluid Volume ___ Excess Fluid Volume ___ Risk for Imbalanced Fluid Volume ___ Hyperthermia ___ Hypothermia ___ Nausea ___ Nutrition, Imbalanced (Less than/More than) Body Requirements ___ Nutrition, Readiness for Enhanced ___ Risk for Imbalanced Nutrition ___ Impaired Oral Mucous Membrane ___ Impaired Skin Integrity ___ Risk for Impaired Skin Integrity ___ Impaired Swallowing ___ Impaired Tissue Integrity ___ Risk for Unstable Glucose Level Other: ______________________________

Elimination Pattern 1. 2. 3.

Is the patient having any problems with bladder and/or bowel elimination? Yes / No If yes to above, describe: ________ When did patient void last? _______________ When did patient have BM last? _______________ What is patient’s usual bowel pattern? ______________________

4.

5. 6.

Abdomen: ___ Soft ___ Firm ___ Non-Tender ___ Tender (location: (___________________) Non-Distended ___ Distended (girth:_____ Incontinent ___ Ostomies/Tubes (type: __________ Can patient care for this? Yes / No)Bowel Sounds: Nursing Diagnoses: MARK APPRORIATE DXS ___ ___ Constipation ___ Risk for Constipation ___ Diarrhea ___ Bowel Incontinence Active ___ Urinary Incontinence ___ Risk for Urinary Incontinence ___ Impaired Urinary Elimination All ___ Readiness for Enhanced Urinary Elimination ___ Urinary Retention Other: Quads __________________________ ___ Hypoactive (which quads? ___________) Absent (which quads? _____________ Bladder: ___ Non-Distended ___ Distended ___ Incontinent (describe: ____________Nocturia ___ Urgency ___ Hesitancy ___ Hematuria ___ Urinary Catheter (type: ___ Is catheter anchored to thigh? Yes / No) Comments: _______________________________________________________________________________

Activity/Exercise Pattern 1. 2.

3.

4.

5. 6. 7.

8.

9.

Does the patient have enough energy for their desired or required activities? Yes / No Does the patient need assistance with: ___ None ___ Eating/Drinking ___ Turning ___ Transfer to/from Bed/Chair ___ Sitting ___ Walking ___ Toileting ___ Bathing ___ Dressing ___ Stair Climbing ___ Shopping ___ Preparing Meals ___ Cleaning House Comments: _________________________________________________________________________________ _________________________________________________________________________________________________ ___________ Mobility Impairments: ___ None ___ Unable to Assess ___ History of Falling ___ Dizziness ___ Unsteady Balance ___ Tremors/Spasms ___ Paralysis ___ Decreased Function ___ Decreased Sensation ___ Amputation Comments: ___________________________________________________________________________ _________________________________________________________________________________________________ Gross Motor Movements: ___ Normal Gait ___ Abnormal Gait ___ Normal Posture ___ Abnormal Posture ___ Full/Active ROM Comments: _____________________________________________________________________________________ Does patient use any assistive devices at home? Yes / No If yes, describe: ___________________________________ Muscle Strength: (see key) ___ Unable to Assess LUE:_______ LLE: ________ RUE:________ RLE :________ Respiratory Assessment Respiratory Effort: ___ Easy ___ Labored ___ Use of Accessory Muscles ___ Orthopnea ___ None Respiratory Pattern: ___ Regular ___ Irregular ___ Shallow ___ Deep Breath Sounds: (describe as clear, diminished, absent, fine crackles or rales, medium crackles, course crackles or rhonchi, wheezes) RUL: _________________________ RML: ____________________________ RLL: __________________-____ LUL: _____________________________ LLL: ________________________ Cough? Yes / No If yes, describe sputum: _______________________________________________________ Supplemental Oxygen? Yes / No If yes, describe type and amount: ___________________________________ Trachesotomy/Mechanical Ventilation/Chest Tube/s: _______________________________________________ ___________________________________________________________________________________________ Comments: _________________________________________________________________________________ ___________________________________________________________________________________________ Cardiovascular Assessment Heart Sounds: _________________ ___ Regular Rhythm ___ Regularly Irregular Rhythm ___ Irregularly Irregular Rhythm Telemetry Reading: ____________________________ ___ JVD Please describe the amplitude of each pulse as 0=absent, +1=weak, +2=normal, +3=bounding or D=dopper. Right Radial: ____________ Right Pedal: ______________ Left Radial: _______________ Left Pedal: ______________ Please describe the capillary refill of each location as brisk, < 3 seconds, or > 3 seconds. RUE: ________________________ RLE: _____________________ LUE: _______________ LLE: __________________ Comments: _______________________________________________________________________________________ _________________________________________________________________________________________________ Comments for Activity/Exercise Pattern:______________________________________________________________

_ Nursing Diagnoses MARK APPRORIATE DXS ___Activity Intolerance ___ Risk for Activity Intolerance ___ Ineffective Airway Clearance ___ Ineffective Breathing Pattern ___ Autonomic Dysreflexia ___ Risk for Autonomic Dysreflexia ___ Decreased Cardiac Output ___ Risk for Disuse Syndrome ___Deficient Diversional Activity ___ Fatigue ___ Impaired Gas Exchange ___ Impaired Home Maintenance ____ Impaired Mobility ___ Risk for Peripheral Neurovascular Dysfunction ___ Self-Care Deficit ___ Delayed Surgical Recovery ___ Ineffective Tissue Perfusion ___ Impaired Spontaneous Ventilation ___ Dysfunctional Ventilatory Weaning Response ___ Impaired Walking Other: ______________________________

Sleep/Rest Pattern 1.

2.

Has the patient had difficulty sleeping prior to admission? Yes / No If yes, describe: ________________________ ___ Difficulty Falling Asleep ____ Early Awakening ___ Daytime sleeping ____ Awakening throughout Night ___ Unable to Assess Comments: _______________________________________________________________________________________ _________________________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS ___ Sleep Deprivation ___ Readiness for Enhanced Sleep Deprivation Other: ________________________________________

___ Insomnia

Cognitive/Perceptual Pattern 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Orientation: ___ X1 ___ X2 ___ X3 Comment: __________________________________________________ Level of Consciousness: ___ Conscious ___ Lethargic/Sleepy/Drowsiness Glasgow Coma Scale Score: ______ Pupils: ___ Equal ___ Unequal ___ Round ___ Irregular ___ Briskly Reactive ___ Sluggishly Reactive ___ Nonreactive Speech: ___ Clear ___ Slurred ___ Receptive Asphasia ___ Expressive Aphasia Primary language if not English: ___________________________________________ Thought Process: ____Logical ____ Illogical (Confused) ___ Flight of Ideas What is the highest grade the patient completed? _____________________ Occupation: __________________________________________________________________________________________ Does the patient have any problem with ST or LT memory? Yes / No If yes, explain: ________________________________ Does the patient have hearing loss? __ R Ear L Ear ___ Both If loss, does patient wear aids? ___ R Ear ___ L Ear ___ Both Does the patient have vision impairment? Yes / No If yes, ___ Prescription Glasses ___ Prescription Contacts ___ Cosmetic Contacts If patient wears contacts, describe type of and care of lenses: _________________________________ Does the patient have impaired ability to feel pain or temperature? Yes / No If yes, describe: ________________________ Has the patient ever had a seizure? Yes / No If yes, when was last and what type? ________________________________ Does the patient currently have pain or any discomfort? Yes / No If yes, use PQRST to thoroughly describe the pain: ____ _____________________________________________________________________________________________________ What does the patient feel he or she needs to be able to take care of him/herself after discharge? _____________________________________________________________________________________________________ Comments: ___________________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS ___Acute Confusion

___ Chronic Confusion ___ Risk for Acute Confusion ___ Decisional Conflict

___Impaired Environmental Interpretation Syndrome ___ Deficient Knowledge ____Impaired Memory ___ Unilateral Neglect ___ Acute Pain ___ Chronic Pain ____ Disturbed Thought Processes Other: _________________________________________ Self-Perception/Self-Concept Pattern 1. 2. 3. 4. 5.

Mood: ___ Calm ___ Agitated ___ Angry ___ Anxious ___ Sad ___ Labile ___ Other Affect: ___ Congruent to Verbal ___ Incongruent to Verbal ___ Flat Verbal Style: ____ Interactive ___ Quiet ___ Talkative ___ Guarded What outcome does patient expect from this hospitalization? _________________________________________________________________________________________________ Comments: _________________________________________________________________________________________________ ________________________________________________________________________________________________ Nursing Diagnoses MARK APPRORIATE DXS

___ Anxiety ____ Death Anxiety ___ Disturbed Body Image _____ Fear ___Hopelessness ___ Risk for Compromised Human Dignity ___ Disturbed Personal Identity _____Risk for Loneliness ___ Powerlessness ____ Risk for Powerlessnes ___ Chronic Low Self Esteem ___ Situational Low Self-Esteem ___ Risk for Situational Low Self-Esteem ___Risk for Self-Directed Violence Other: _____________

Role/Relationship Pattern 1. 2. 3. 4.

5. 6.

Lives: ___ Alone With: ________________________________________________________________________ Who will assist the patient with his/her care after discharge? ______________________________________________ Resides: ___ House ___ Mobile Home ___ Apartment ___ Assisted Living ___ LTC Facility Does the patient have any environmental or safety concerns with living arrangements (ie. stairs, inaccessible bathrooms)? Yes / No If yes, explain: ______________________________________________________________________________ Does patient report any family disturbances that are of concern to him/her? Yes / No If yes, explain: _________________________________________________________________________________ Comments: ___________________________________________________________________________________

Nursing Diagnoses MARK APPRORIATE DXS ___ Caregiver Role Strain _____ Risk for Caregiver Role Strain ____ Impaired Verbal Communication ___ Dysfunctional Family Processes ____ Interrupted Family Processes ____ Grieving ___ Risk for Impaired Parenting ____ Ineffective Role Performance ___ Impaired Social Interaction ___ Social Isolation ____ Chronic Sorrow ___ Risk for Other-Directed Violence Other: ___________________________________

Sexuality/Reproductive Pattern 1. 2.

3.

Does the patient have any questions or concerns about the effects of his/her physical condition or treatment on his/her sexual activity? Yes / No If yes, explain: ______________________________________________________ Females: Date of LMP: _______________ How long is normal menstrual cycle? __________________ Has the patient experienced any changes in recent menstrual cycles (length/flow)? Yes / No If yes, explain: __________________________________________________________________G: ___ P: ___ A: ___ L: ___ Comments: _________________________________________________________________________ _

Nursing Diagnoses MARK APPRORIATE DXS ___ Rape-Trauma Syndrome ___ Sexual Dysfunction Other: _________________________________

____ Ineffective Sexuality Patterns

Coping/Stress Tolerance Pattern 1. 2. 3. 4.

Has the patient had any recent major life-style changes? Yes / No If yes, explain: ________________ How does the patient deal with stressful situations? _________________________________________ ____________________________________________________________________________________ Does the patient feel the coping mecha...