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New Assessment Form 2 | Respiratory System | Urinary Incontinence

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CAPITOL UNIVERSITY College of Nursing NURSING ASSESSMENT FORM A. Demographic Data Name of Client _________________________________________ Unit/Ward __________ Bed ________ Age _________ Sex _________ Civil Status _____________ Religion ___________________________ Date of Admission _______________________ Medical Diagnosis ____________________________________________ Examiner ________________________________ Information given by ________________________________________ B. Vital Signs Temp ______
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  CAPITOL UNIVERSITYCollege of Nursing NURSING ASSESSMENT FORM A. Demographic Data  Name of Client _________________________________________ Unit/Ward __________ Bed ________ Age _________ Sex _________ Civil Status _____________ Religion ___________________________ Date of Admission _______________________ Medical Diagnosis ____________________________________________ Examiner ________________________________ Information given by ________________________________________  B. Vital Signs Temp ___________   oral  axilla  rectal BP ___________   lying  sitting  standingPulse ___________/ min.  regular   irregular Resp ___________/ min.  regular   irregular Height ___________ cm. Weight ____________ kg. C. Health Patterns Assessment: Complete information, including patient’s words. Indicate N/A if non-applicable. Circle,code, or check all findings as appropriate. 1.Health Perception and Health Management Pattern Reason for hospitalization/chief complaint ________________________________________________________________  ___________________________________________________________________________________________________  ___________________________________________________________________________________________________ History of present illness ______________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________ Previous hospitalizations/surgeries_________________________________________________________________________  _____________________________________________________________________________________________________  ____________________________________________________________________________________________________ What other health problems have you had? __________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Things done to manage health ____________________________________________________________________________  ____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Statement of patient’s general appearance ___________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Tobacco use:  Yes  No Used to smoke ______________ packs/day for __________ yearsAlcohol use:  Yes  No Amount: _______________ Frequency: _________________ Duration: _____________ Coffee/Cola/Tea Intake:  Yes  No Amount: ___________ Frequency: ____________ Duration: _____________ Recreational/Illicit Drug use:  Yes Specify: _____________________   NoAllergies:  Yes (list with reaction experienced)  NoFood: __________________________________________ Medications:_____________________________________ Others: ________________________________________________________________________________________  Medications:  NAMEDOSESCHEDULEINDICATIONSHave you been taking your medication(s) as prescribed? ________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________   2.Nutrition and Metabolic Pattern Special diet? _____________________________________________ Supplements: ________________________________ Pattern of daily food/fluid intake (describe amount/quantity) ____________________________________________________  _____________________________________________________________________________________________________ Appetite: ________________________________________________ Wt. loss/gain? ________________________________  Nausea/Vomiting: _________________________________________   Hematemesis  Coffee-ground vomitusFood/eating discomforts________________________________ GI pain ___________________________________________  Nutritional state:  well-nourished  poorly nourished  obesity  cachexia  Mouth: Lips:  pinkish  pallor   cyanosis  dryness/cracks  lesions: ________________________________ Mucosa:  pinkish  pallor   cyanosisTongue:  midline  R/L deviation  atrophy  fasciculationTeeth:  complete  missing teeth  caries  dentures: ________________ Gums:  pinkish  pallor   bleeding  tenderness   Pharynx: Uvula:  midline  R/L deviation Mucosa:  pinkish  pallor   reddishTonsils:  not inflamed  R/L inflamed  R/L with exudatePosterior Pharynx:  inflammation/congestion  Neck: Trachea:  midline  R/L deviation Cervical lymph nodes:  lymphadenopathy  tendernessThyroids:  non-palpable  enlarged Others:  neck enlargement  normal ROM  neck rigidity  Skin: General Color:  pinkish  pallor   jaundice  dusky  cyanotic  flushed  mottledTexture:  smooth  rough  others: __________________________ Turgor:  supple  firm  dehydrated  others: ___________________________ Temperature:  warm  cool  others: ______________ Moisture:  dry  moist/clammy  oilyOthers:  petechiae  ecchymosis  hematoma  lesions/rashes: ____________________________________    edema: ____ pitting ____ non-pitting ____ pedal: R/L ______ bipedal Grading: ____________ Wounds/drains/dressings: _________________________________________________________________________________ Intravenous fluids _______________________________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________  3. Elimination Pattern Usual bowel pattern (describe character of stool, frequency, discomforts) ___________________________________________  ______________________________________________________________________________________________________  _________________________________________________________________ Date of last BM: ______________________    Melena  HematocheziaAny problems with hemorrhoids/incontinence? _______________________________________________________________ Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies” anti-diarrheals): _______________  _____________________________________________________________________________________________________   Abdomen: General :  superficial veins  straie  scars/lesions: ____________________ Configuration:  symmetrical  asymmetrical  flat  globular   protuberant  scaphoidBowel Sounds:  normoactive  hyperactive  hypoactive  absentPercussion:  tympanitic  hypertympanitic  dullness at _________________________________    fluid wave  shifting dullnessPalpation:  muscle guarding  direct tenderness  rebound tenderness  bladder distention   organomegaly: ___ liver ___ spleen  masses at _____________________________________ Usual urinary pattern (describe frequency, character, amount, problem in control, etc.) ________________________________  ______________________________________________________________________________________________________    dysuria  hematuria  nocturia  retention  flank pain  polyuria  oliguria  anuriaExcess perspiration/nocturnal sweats: _______________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________  4.Activity – Exercise Pattern Exercise Pattern? (Type, Regularity) _______________________________________________________________________ Leisure Activities? _____________________________________________________________________________________  Cardiovascular Status:  chest pain/radiation: _______________________   palpitations  dyspnea on exertion   orthopnea  paroxysmal nocturnal dyspnea  jugular vein distentionPrecordial area:  flat  bulging  tenderness  heave  thrillPoint of Maximal Impulse (PMI) _____________________ Apical rate & rhythm _____________________________ Heart Sounds:  distinct  regular   faint  irregular S1 < > S2 at the base S1 < > at the apexOthers:  S3  S4  Murmur best heard at ________________   Pericardial rub  Peripheral pulses:  symmetrical  regular   absent  faint/weak   strong  boundingCapillary refill __________________________   clubbingPresence of Pacemaker/A-V Shunt/Hemodynamic monitoring ______________________________________________   Respiratory Status: Breathing Pattern:  regular   irregular   eupnea  hyperpnea  tachypnea  bradypnea   dyspnea: rest / exertion  use of accessory muscles  ICS retractions/bulging  pain on respirationShape of Chest: Anterior-Posterior-Lateral Ratio AP_____: L_____   barrel chest  funnel  pigeonLung Expansion:  symmetrical  R / L decreased/lagVocal/Tactile Fremitus:  symmetrical  decreased / increased at _________________ Percussion:  resonant  dullness at ___________________   hyperresonant at ___________________ Breath Sounds:  vesicular   bronchovesicular at _________________   bronchial at __________________    rales/crackles at______________   wheezes at ___________________   rhonchi  pleural friction rubCough:  productive  non-productive Sputum: color _________ amount________ consistency __________ O2 supplement/ventilatory assistance_______________________________________________________________________ Resp. tubes (e.g. ET, trach, chest tube – describe secretions/drainage)_____________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________ ____________________________________________________________________________________________________   Activities of Daily Living/ Mobility Status: Use the Activity Level Code below to assess ADL & mobility statusADL Status Mobility Status0 – total independence Feeding ________ Meal Preparation_____ Bed mobility _____________ 1 – assist with device Bathing ________ Cleaning __________ Chair/toilet transfer________ 2 – assist with person Dressing _______ Laundry __________ Ambulation ______________ 3 – assist with device & person Grooming ______ Toileting __________ R.O.M. _________________ 4 – total dependenceReasons for ADL/Mobility limitation _______________________________________________________________________ Device used for assistance ________________________________________________________________________________ Exercise pattern (describe type, regularity) ___________________________________________________________________   Back and Extremities: Range of Motion:  full  symmetrical  decreased ROM (specify joint) _________________    Joint tenderness/pain  joint swelling at ________________   varicose veins  deformities _____________ Muscle tone and Strength:  equally strong  symmetrical in size  R / L Upper / Lower Atrophy   R / L Upper / Lower Paresis  R / L Upper / Lower ParalysisSpine:  midline  Kyphosis  Lordosis  ScoliosisGait:  coordinated  smooth  uncoordinated  shuffling  staggeringOTHER PERTINENT DATA _____________________________________________________________________________  ______________________________________________________________________________________________________  5. Cognitive – Perceptual Pattern Level of Consciousness:  conscious  alert  confused  drowsy  stuporous  comatose  others_______ Orientation:  oriented  disoriented to : time / person / placeEmotional state:  calm  worried/anxious  restless  others: ______________________________________ Appropriate behavior/communication: ______________________________________________________________________    dizziness  numbness  tingling sensation  Head:  normocephalic  asymmetrical  enlarged  masses: _____________   others: ___________________ Facial Movements:  symmetrical  asymmetrical: lag at R / LFontanels:  closed  sunken  bulging  open: specify _____________________ Hair:  fine  coarse  dry  normal/even distribution  alopeciaScalp:  clean  dandruff   lice  wounds/scars/lesions: specify_______________________________   Eyes: Lids:  symmetrical  R / L edema/swelling  R / L ptosis  lesions: __________________________ Periorbital region:  edema  sunken  discolorationConjunctiva:  pink   pale  lesions  dischargesCornea & Lens:  opacity: R / L  lesions: __________ Sclera:  anicteric  subicteric  icteric  hemorrhagesPupils:  equal: size _____mm.  unequal: R= _____mm. L= _____mm.Reaction to Light: R -  brisk   sluggish  fixed L -  brisk   sluggish  fixedReaction to Accommodation:  uniform constriction / convergence  unequal constriction / convergenceVisual Acuity:  grossly normal  farsighted  nearsighted  wears eyeglasses/contact lensesPeripheral Vision:  intact/full  decreased/ limited: _________________________   Ears: External Pinnae:  normoset  symmetrical  tenderness  lesions  gross abnormalities ______________ External Canal:  discharge: ___foul smelling ___ serous ___ purulent ___mucoid  Cerumen: ____impactedTympanic Membrane:  intactGross Hearing:  normal  decreased  symmetrical  R / L deafness  Nose:  alar flaring  shallow nasolabial fold Septum:  midline  deviated  perforated  Mucosa:  pinkish  pale  reddish Discharge:  serous  mucoid  purulent  bloodyPatency:  both patent  R / L obstruction  masses/lesions: describe __________________________________ Gross Smell:  normal/symmetrical  R / L olfactory deficiencySinuses:  tenderness: ____ maxillary ____ frontal Cognition: Primary language _________________________ Speech deficit _____________________________________ Educational attainment ______________________________________________________________________________ Any learning difficulties? ____________________________________________________________________________ Any change in memory lately? ________________________________________________________________________   Pain:  no problem  problem ( describe location, type, intensity, onset, duration of pain) ________________________ _________________________________________________________________________________________________ Methods of pain management: ________________________________________________________________________  6.Sleep – Rest Pattern  Usual sleep/rest pattern: _______________________________________________________________________________ Adequate  yes  no Factors affecting sleep/rest: ______________________________________________________ Methods to promote sleep _____________________________________________________________________________ History of sleep disturbances ___________________________________________________________________________  7.Self-perception and Self-concept Pattern How do you describe yourself ? ________________________________________________________________________    Are there any ways you feel differently about yourself since you’ve been ill/hospitalized? __________________________ __________________________________________________________________________________________________ Description of non-verbal behaviors: ____________________________________________________________________ _________________________________________________________________________________________________  8.Role – Relationship Pattern Marital status _____________ Age and health of significant other _____________________________________________ Age and health of children ____________________________________________________________________________ __________________________________________________________________________________________________ Illnesses in the family ________________________________________________________________________________ Live  alone  family  others: ___________________________________________________________________ Family feelings regarding illness/hospitalization ___________________________________________________________ __________________________________________________________________________________________________ Who are the people that will help you most at this time? _____________________________________________________ Occupation: (any stresses/hazards?) _____________________________________________________________________ Financial support system: ______________________________________________________________________________  9.Sexuality – Reproductive Pattern  Any changes/problems with sexual relations? ________________________________________________________________  Female: Menstrual pattern:___________________________________ Problems/changes: ____________________________ Date of LMP _________________________ Pregnancy history ____________________________________________ Use of birth control measure  yes  no  N/A Type: _____________________________________________ Any problem with use ? ______________________________ Monthly self-breast exam  yes  no   External Genitalia: Labia:  symmetrical  asymmetrical  lesions __________________    pinkish  discoloration  edemaUrethra:  pinkish  red/inflamed Vaginal Orifice Discharge:  purulent  bloody  foul-smellingOthers:  swelling  lumps/nodules   Breast:  equal  unequal Surface:  smooth  retraction  dimpling  edema  lesions   tenderness  masses at _____________________   others: __________________________  Male: Prostate problems? _____________________________ Monthly self-testicular exam  yes  no   Penis:  discharge ________________   nodules/growths/lesions  tendernessScrotum:  equal shape w/ L lower than R   non-tender   R/L enlargement  R/L undescended testes   tenderness  nodules/growths/lesionsOthers:  hernia  hydrocoele 10. Coping – Stress Tolerance Pattern Have you experienced any recent stressful situations in addition to your illness/hospitalization?  Yes  NoIf “Yes”, please describe briefly _______________________________________________________________________  __________________________________________________________________________________________________ Are there any ways we can be of assistance? ______________________________________________________________ How do you usually manage stresses? ___________________________________________________________________ What do you do for relaxation? _________________________________________________________________________ Support groups/counseling resources used: _______________________________________________________________ Were they helpful? __________________________________________________________________________________  11.Value – Belief Pattern
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