Patient Assessment Form Spring 2021 PDF

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Assessment form...

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1 The University of Texas at Arlington Nursing 3632 - Clinical Nursing Foundations Patient Assessment Form Date: Patient Info

Age:

Gender:

Student Name: Allergies & Reaction:

Admitting Complaint (Subjective):

Height:

Weight:

Code Status and Advanced Directives:

Admitting Medical Diagnosis:

Past Health History, Surgical History, Lifestyle and Health Practices Past Health History

Adult Illnesses (physical, emotional, mental): Surgeries (dates):

Family : History

Parents: Living? Deceased Date? Parents’ Illnesses: Grandparents’ Illnesses: Children’s ages and illnesses or handicaps: Activity (Independence): Sleep and rest pattern: Current medication(s): Substance use: Social support: Stress Level and Coping

Preadmission Lifestyle and Health Practices

Vital Signs, Safety, Hygiene, Activity, Intake & Output Vital Signs Time

Pain: 0-10.

Temp (F°)

Time

Pulse

Resp.

Score

BP

Pulse Oximetry (%)

Currently infusing IV fluid or medication (with substance & rate)

O2 Device & Rate /Setting

COLDSPA (Character, Onset, Location, Duration, Severity, Pattern, Associated Factors):

Pain Rating (0-10) If your patient has pain, there should be a reassessment of patient’s pain level after each intervention.

2 Safety (All areas must be complete to receive credit) ID Bracelet (yes/no): Allergy Bracelet: Fall Risk Bracelet: Side Rails Up x _____ Brakes On Bed/Chair & Bed Low: Call Bell in Reach: Restraints: Alternatives to restraints: Isolation/Precautions (select all that apply) Standard: Contact: Droplet: Organism & Location (if on isolation, must include):

Hygiene (All areas must be complete to receive credit) Bath Type Independent: Needs Assist: Bed Bath/Total Care: Bath Given? _____ Oral Care Teeth Brushed: Oral Swabs: Denture Care: Other Perineal Care: Catheter Care: Linen Change: Gown Change: Skid Proof Socks:

Activity (All areas must be complete to receive credit) Activity Independent: Up with Assist: Bedrest: Turn Q2:

Ambulation Distance (feet): Walker: Cane: Crutches: Other:

CRITICAL THINKING POINT: Using your critical thinking skills to briefly discuss the vital signs, safety, hygiene, and activity orders for your patient. A few examples for your discussion may include: Are there any vital signs that you are concerned about? How will this information impact the care you provide for your patient? Why does your patient have a particular order in the above section? How will you ensure that the orders are implemented, and the patient is compliant?

3 INTAKE Time

PO (mL)

IV (mL)

TF (mL)

Diet (%)

Other (mL)

Urine (mL or voids)

Stool (mL or times)

OUTPUT Emesis NGT (mL or Suction times) (mL)

Drains (mL)

Other (mL)

Breakfast:

Lunch:

Snack: SHIFT TOTALS CRITICAL THINKING POINT: Using your critical thinking skills briefly discuss the intake and output of your patient. What is the fluid status of your patients? Does the patient require I&O monitoring? Does this status need adjusted for your patient? Does the fluid status have any impact on the care of your patient? What nursing interventions can be implemented?

4 Physical Assessment Instructions: Complete the following assessment of your patient using YOUR observation, interviewing, and physical assessment skills. *Note: more in-depth focused assessments may need to be completed based on your patient’s diagnosis. * All areas must be complete to receive credit. **Highlight the priority assessment for your patient. Neuro/Level of Consciousness

Oriented to person, place, date/time, situation: PERRLA: General observation of speech: Response to commands: Paresthesia (location): Seizure precautions: Other assessment data:

Psychosocial

Posture: Appropriate hygiene: Changes in voice tone, rate of speech: Mood: Affect: Able to express feelings: Primary language: Interpreter needed? Other assessment data:

Sensory Equipment

Glasses: Contact lenses: Hearing aids: Dentures: Other sensory equipment in use:

Respiratory

Character of respirations (regular/irregular; labored/unlabored): Breath sounds (all locations must be auscultated: 4 anterior, 6 posterior, 2 lateral) Upper Thorax Anterior: Posterior: Lateral: Lower Thorax Anterior: Posterior: Cough (present, non-productive/productive): Sputum/secretions (describe): Oxygen in use (delivery device, flow rate, humidified):

5 Airway (patency at risk): Suction in use: Aspiration Risk: HOB elevation: Equipment in use (nebulizer, incentive spirometry, chest tube, etc.): Other assessment data: Cardiovascular

Heart sounds (regular/irregular, murmur, extra sounds. All locations must be auscultated): Telemetery in use (include heart rhythm if in place): AICD (internal defibrillator)/Pacemaker in use: Other equipment (Lifevest, etc.): Other assessment data:

Peripheral Vascular

Pulses (bilaterally, grade) Radial: Posterior tibialis: Dorsalis pedis: Other: Circulation (bilaterally) Hands (temperature, color, capillary refill x10 fingers): Feet (temperature, color, capillary refill x10 toes): Other (if amputations present, pick most distal site): Edema (location, pitting/nonpitting, severity): SCDs/TED hose in use (specify): Other assessment data:

Integumentary

Intact/not intact: Color: Turgor (elastic/tenting): Moisture: Temperature: Oral mucous membranes (dry/moist, color): Braden Scale Score (form can be found in Canvas ): Drains (wound vac, JP drain, hemovac, T-tube, Penrose drain, etc.) Type: Location: Color of drainage: Other assessment data:

Wound Documentation (if present) *if more than one wound, describe each one separately

Type (pressure ulcer, tear, laceration, incision, etc.): Pressure ulcer stage (ONLY IF pressure ulcer): Location: Appearance of wound bed and peri wound: Wound edges (approximated/not approximated, rolled, undermining, etc.): Size: Exudate/drainage Odor:

6 Amount: Color (serosanguinous, sanguineous, purulent, serous): Dressing or closure device Type: Appearance (intact/not intact/loose, clean/moist/saturated): Frequency of dressing changes and date last changed: Other assessment data: Musculoskeletal

Moves all extremities with ease: Equal grip bilaterally: Strength (in all extremities, grade): ROM (in all extremities, full/limited, active/passive): Joints (swelling, heat, tenderness, location): Gait (steady/weak/unsteady, needs assistance to transfer): Morse Fall Scale Risk (see attached scale and fill out) OR HDS per Clinical Instructor: Ambulatory or recovery equipment in use: Other assessment data:

Gastrointestinal

Inspect (round, flat, distended, etc.): Auscultate (BS x 4 quadrants): Palpate (soft, firm, masses, pain, in all 4 quadrants): BM (last BM, color): Bristol Stool Chart type (see attached scale): Passing flatus: Nausea/vomiting (present/not present, color of emesis): Equipment in use (abdominal binder, etc.): Other assessment data:

Nutrition

Enteral Nutrition Route (PO/NG/PEG/etc.): Diet order (regular, diabetic, cardiac, renal, TF, clear liquid, etc.): *If tube feeding order Type of TF: Continuous (rate)/Bolus (amount, frequency): Solid consistency (regular, mechanical soft, ground, pureed, etc.): Liquid consistency (regular, nectar thick, honey thick, etc.): Parenteral Nutrition Route (central line/PICC): Nutrition order (TPN, PPN, Clinimix, etc.): Rate:

7 Genitourinary

Voiding Method (BRP, bedpan, urinal, BSC, catheter, etc.): Continent/Incontinent: Difficulty or pain with urination: Equipment in use (Foley, straight catheter, suprapubic catheter, urostomy, condom catheter, Purewick): Date of insertion: Size of device: Indication: Urine Color: Clarity: Odor: Sediment: Kidney function Total shift output: How many mLs per hour (total urine output for YOUR shift/hours on unit): Dialysis (if yes, peritoneal or hemodialysis): Other assessment data:

IV Site *if more than one IV is present, document on all separately

Type (PIV, PICC, central line, etc.): Date of insertion: Size (gauge) and location: Insertion site assessment Color: Swelling: Streaking: Dialysis Access and Location:

Temperature: Pain: Intact/leaking:

8 Lab and Diagnostic Data Instructions: Pick 3-5 lab and/or diagnostic results that are pertinent to your patient and their diagnoses. Provide the lab/test name, the patient’s result, the normal range and how it pertains to your patient and their diagnoses. Lab/Diagnostic Normal Range Why is this pertinent to the patient’s disease process? Name and Result

NANDA Diagnostic Statements based on assessment https://kb.nanda.org/article/AA-00492/0/How-do-I-write-a-diagnostic-statement-for-risk-problem-focused-and-health-promotion-diagnoses.html Identified NANDA (Problem Focused or Risk) (NOTE: Patient risk diagnosis cannot merely be converted to an existing problem focused diagnosis by subtracting “Risk for”)

Related To (R/T) (What do you believe is causing the identified problem?)

Problem Focused Diagnosis Problem Focused Diagnosis Problem Focused Diagnosis

Risk Diagnosis Risk Diagnosis

---------------------------------

As Evidenced By (AEB) What data did you collect that supports your identified problem or risk?

9 Hourly Rounding for Patient Safety and Satisfaction Questions to Consider: Positioning- Change position at least Q2H (right, left, supine). Is patient in a comfortable position- to facilitate breathing? Is patient at risk for pressure ulcers? Has position changed? Is HOB elevated as needed- tube feeding? Are extremities in functional positions- including extremity with IV site if applicable? Potty- Does patient need to get up to the bathroom? Does patient need a urinal? Is Foley tubing positioned without dependent loops? Personal Needs- Is the call light within easy reach? Are personal care items, such as tissues and drinking water, within easy reach? Does room look like you would want your family member’s room to look? Pain- does patient have obvious signs of pain or discomfort? What is the pain rating? Safety- Side rails up? Bed in lowest position? Cords, equipment, etc. placed to avoid accidental falls? ID band? Correct IV flow rate? IV site without problems?

Position Potty Personal Pain Safety

Example: Right Side Denies need Yes 2/10 Rails x3, yes

0700

0800

0900

1100

1200

1300

1400

1500

10 Medications – ALL MEDICATIONS NEED TO BE RESEARCHED PRIOR TO ADMINSTRATON. Failure to do research prior to administration could result in clinical failure Medication Name, Dose, Frequency, Route Pharmacologic class:

Indications & Dosages Is this dose safe?

Medication Reconciliation Is this a new med for the patient? Was the patient taking this medication at home? Has the home dose been adjusted?

Assessment Findings and Lab values pertinent to medication

How does this med effect pathophysiology or disease process? Why is the patient receiving this drug? ACTION OF THE MEDICATION

Common and / or serious side effects & nurse’s role in treating or preventing those side effects? Interactions

Patient Teaching

11

End of Shift Note This should be a quick summary of your day. Did anything unexpected happen? What did you do and how did the patient respond? Were your interventions effective? Did the patient have a procedure? Was safety maintained? Etc. Sign and date as well. THIS IS NOT A PLACE TO REITERATE YOUR ASSESSMENT...