Description
Unformatted Attachment Preview
Student Name: ____________________________
Date: _________________
Nursing History/Assessment
Older Adults.
Patient Initials: _______
Patient age: ____
Ht: _____
Wt: ________
Primary Diagnoses:
Knowledge and understanding of health problems: (state what patient says)
Limitations of function and performance of ADLs:
Management of limitations:
Health goals:
Medications list and state what patient says each medication is for in quote marks.
Skin Condition:
Dominant hand:
Oxygenation/Perfusion assessment:
Smoking History:
Pulse, Temperature and color in extremities:
Nutrition/Hydration:
1
Usual meal pattern:
Food preferences:
Food restrictions:
Fluid intake:
Alcohol Abuse:
Appetite:
Elimination: (bowel, bladder, voiding and defecation pattern, use of laxatives?)
Rest:
Female reproductive factors:
Date of last GYN exam: _________________
Last Mammogram: _____________
Sexual profile:
Cognitive/Perceptual:
Date of last hearing exam: _________________________________
Date of last vision exam: __________________________________
Mental Status:
Attention span:
2
Emotional status:
Esteem
Self-concept:
Current concerns:
Spirituality:
Durable power of attorney: _______________________________________
Living will:
Three top nursing diagnoses for this patient (R/T and M/B)
1)
2)
3)
NURSING PROCESS
Subjective Data:
Objective Data:
One Nursing Diagnosis from above:
Goal:
Interventions to achieve above goal:
1)
2)
3)
Evaluation:
Gerontological consideration:
3
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