RN INITIAL ASSESMENT

Description

THIS ASSIGNMENT MUST BE COMPLETED AS A PATIENT COMING IN WITH COLLAPSED LUNG. FILL OUT LIKE YOU ARE DOING A PATIENTS CHARTS. PATIENT COMES IN WITH COLLAPSED LUNG, VAPING. YOU ARE ABLE TO MAKE IT UP, BUT MAKE IT REALISTIC. MEDICATIONS MUST BE LISTED, TREATMENT AND WHATEVER IT ASKS. IT IS OK TO FILL IT UP HOWEVER YOUD LIKE. I WILL BE PRINTING IT OUT AND WRITING IT MYSELF WITH BLCK INK

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Nursing Initial Assessment
Date:
Time:
□ Patient
Informant:
_
□ Other _________________________
Reason for Admission (Pt’s own words): __
Vital Signs
T
O
A
R
T
P
Reg
SaO
R
A
or
O
2
2
Irreg
R
BP
Ht
Wt
Kg
BMI
Allergies
Allergi
es
Allergi
es
Reaction
Reacti
on
Allergies
Reaction
Latex? Y or N
Chronic Conditions
□ Lung Problems
□ Stomach Problems
□ Thyroid Problems
□ Neurological Problems
□ Heart Problems
□ Liver Problems
□ Vision Problems
□ Kidney Problems
□ Arthritis
□ Diabetes
□ Chronic infection Treatment: ________________________________
□ Cancer (Where/Type): ___________________________________________________________ Treatment: __________________________________________
Other Past Medical History and Surgeries: _______________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
□ Family History – □ NSF
□ Heart Disease
□ Hypertension
□ Diabetes
□ Stroke
□ Seizures
□ Kidney Disease
□ Liver Disease
Medications
Medication
(include OTC)
Dose
Frequency
Ta k e n
today
? Y or
N
Broug
ht
with?
Y or N
Medications
(include OTC)
Dose
Frequency
Taken
today?
Y or N
Broug
ht
with?
Y or N
Social History
□ Lives Alone
□ Lives With: ______________________________________________________________________________ Stairs At Home? □ Yes □ No
Sleep Pattern: _______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Immunizations Current? □ Yes □ No
Last Tetanus Toxoid: _______________________________________________________________________________
Nicotine Use:
□ No □ Yes – How much? ___________________________________ How Long? ________________________________________
Do you live in a smoking environment? □ Yes □ No
Alcohol Use:
□ No □ Yes – How much? ____________________ How Long? ____________________ Last Drink?
______________________________________________
Social Drug Use:
□ No □ Yes – Type?
Frequency?__________________________________________________
Support Services:
□ No □ Yes – Type □ HHC □ Hospice □ Other
___________
Additional Help needed? □ No □ Yes – Referral made to
Impairment / Disabilities
Yes
No
Yes
No
Yes
Impaired hearing
Hearing Aid
RL
Impaired vision
Glasses
Crutches
Can perform ADL?
Contacts
Wheelchair
Can read?
Dentures
Can write?
Partial
No
Walker
UL
Cane
Prosthesis
Home O
Rate:
2
Other:
Dietary
Habits
Special Diet: ________________________________________________________________________________
Supplements: _________________________________________________________________________________
Safety
ID Band On? □ Yes □ No
Oriented to Unit? □ Yes □
Skin Integrity Assessment Scale:
Fall Risk Assessment Scale:
______________________________________
_______________________________
IV Pump? □ Yes □ No
No Call Bell Within Reach? □ Yes □ No
Toiletry Supplies Offered? □ Yes □ No
If 17 or below, Skin Risk initiated.
If above 25, Fall Prevention initiated.
Skin Risk Assessment Scale:
Sensory Perception
Ability to respond to pressure related
discomfort
1. Completely limited –
unresponsive to pain or limits
ability to feel pain over most of
body
2. Very limited – response to painful
stimuli or limits ability to feel pain over ½ of
body, or paralysis present
3. Slightly limited – response to
verbal command but can’t always
communicate
4. No Impairment – able to
verbalize feelings and complaints
Moisture
Skin exposed to moisture
1. Constantly moist – (i.e.
perspiration, urine)
2. Very moist – extra linen change
1x per shift
3. Occasionally moist – linen
change 1x per day
4. Usually dry – no extra linen
changes
Activity
Degree of physical activity
1. ABR
2. Chair fast – NWB/WC must be
assisted to chair
3. Ambulates occasionally –
with assist up in chair
4. Ambulates frequently
Mobility
Ability to change and control body
position
1. Completely immobile
2. Very limited – unable to make
frequent changes independently
3. Slightly limited – makes frequent
slight changes for self
4. No limitations
Nutrition
Food intake pattern
1. Very poor – NPO, Clear
liquids, or IVs > 5 days. Takes
f l u i d s p o o r l y. U n d e r w e i g h t ,
malnourished.
2. Inadequate – eats < ½ meal. Takes less than optimum 3. Adequate – eats > ½.
Tube feeding or TPN
provides needs
4. Excellent
Friction
1. Problem – requires assist in
moving. Frequent friction. History
of skin tears or pressure sores.
2. Potential – requires minimum
assist, occasional friction
3. No apparent problem – BRP
4. Up ad Lib
Fall Risk Assessment Scale:
Confused – disoriented – hallucinating
20
Post-op condition – sedated
10
Narcotics, diuretics, antihypertensives, etc.
10
Unstable gait, weakness
20
Drug or alcohol withdrawal
10
Bowel, bladder urgency – incontinence
10
Hx of syncope or seizures
15
Use of walker, cane, crutches, etc.
10
Age 70 or above
5
Recent hx of falls
15
Postural hypotension
10
Uncooperative, impaired judgement
5
Age 12 or younger
15
Poor eyesight
10
Language barrier
5
Paralysis, hemiplegia, stroke
15
New meds (i.e. sedative, antihypertensive)
15
Poor hearing
5
Part II – Systems Review
* NSF = No significant findings
Check appropriate box if present – if box not checked, sign/symptom not present
Eyes: □ WNL
□ Yes □ No Blurred Vision
□ Yes □ No Color Blind
□ Yes □ No Double vision
□ Yes □ No Itching
□ Yes □ No Drainage — Color
Amount
□ Yes □ No Inflammation
□ Yes □ No Pupils Abnormal
□
□ Yes □ No Pain
Yes □ No Other
Ears: □ WNL
□
Yes □ No HOH (R) (L) □ Yes □ No Deaf
□
Yes □ No Drainage
□
Yes □ No Other
Nose: □ WNL
□ Yes □ No Congestion
□ Yes □ No Nasal Flaring
□ Yes □ No Drainage – Color
□ Yes □ No Other
□ Yes □ No Tinnitus
□
□ Yes □ No Dizziness
Yes □ No Sense of Balance
□ Yes □ No Pain
□ Yes □ No Alignment
□ Yes □ No Pain
□ Yes □ No Sinus Problems
□ Yes □ No Nosebleeds – Frequency
Amount
Mouth: □ WNL
□ Yes □ No Halitosis
□ Yes □ No Sense of Taste
Dental Hygiene
Throat/Neck: □ WNL
□ Yes □ No Sore Throat
□ Yes □ No Stiffness
□ Other
□ Yes □ No Pain
□ Yes □ No Bleeding Gums
□ Yes □ No Lesions
Last Dental Exam
□ Yes □ No Hoarseness
□ Yes □ No Pain
□ Yes □ No Lumps
□ Yes □ No Dysphagia
□ Yes □ No Swollen glands
Neurological: □ WNL
□ Yes □ No Cooperative
□ Yes □ No Dizziness
□ Yes □ No Memory Changes
□ Yes □ No Headaches
□ Yes □ No Oriented
□ Yes □ No Other
Oriented to:
□ Yes □ No Person □ Yes □ No Place □ Yes □ No Time Pupils
Size:
Deviation:
□ Yes □ No PEARLA
Reaction: □ Brisk □ Sluggish □ No Response
LOC
□ Alert
Speech □ Clear
Grips:
Respiratory:
□ Confused
□ Sedated
□ Somnolent
□Comatose
□ Agitated
□ Other
□ Slurred
□ Aphasic
□ Dysphasia
□ None
□ Other:
Foot pushes:
Gag reflex:
□ Other:
□ WNL
Lung sounds:
Dyspnea
□ None
Cough
□ None
Chest Symmetry □ Yes
□ Yes □ No Night Sweats
□ Other:
□ With activity
□ At rest
□ Lying down
□ Retractions
□ Non-productive
□ Productive – Color
Amount
□ No – □ Barrel
□ Funnel
□ Other
□ Yes □ No Hemoptysis
□ Yes □ No Cyanosis – Where
Cardiovascular: □ WNL
□ Regular
Cardiac Rate or Monitor pattern:
□ Yes □ No Chest Discomfort –
Where:
Duration
□ Yes □ No Pulse Radial (R)/(L)
□ Yes □ No Pulse Pedal (R)/(L)
□ Yes □ No Edema – Location
□ Yes □ No Pacemaker – Date Inserted
Type:
□ Yes □ No Murmur
□ Irregular
Intensity (1 – 10)
Resolution
□ Irregularly irregular
Onset
□ Yes □ No JVD (R)/(L)
□ Pitting
□ Non-pitting
Where:
Skin – Extremi es – Musculoskeletal: □ WNL
ti
Skin
□ Warm
□ Cool
□ Dry
□ Firm
□ Flaccid
Color:
□ Yes □ No History DVT
□ Yes □ No Homans (R)/(L)
Extremities
□ Yes □ No Tingling
□ Yes □ No Weakness
□ Yes □ No Deformity
Joints
□ Yes □ No Pain
□ Yes □ No Stiffness – Location:
□ Yes □ No Replacement – Date
Where:
ROM
□ WNL
□ Other (location/ range):
□ Yes □ No Contractures
Physical Findings: □ WNL
Describe and graph all abnormalities by number:
1.
Bruises
2.
Incisions
3.
Lacerations
4.
Rashes
5.
Decubitus
6.
Dryness
7.
Scars
8.
Lesions
9.
Abnormal color
10.
Other :
11.
Tattoos
12.
Body Piercing
13.
Skin Tear/ Duoderm/Op-Site
Gastrointes nal: □ WNL
Appetite
Last BM
□ Good
Date:
Bowel sounds
□ Poor
Color
□ Recent change
Frequency:
□ Yes □ No Laxative use – Type
Frequency
□ Yes □ No Constipation
□ Yes □ No Diarrhea
□ Yes □ No Nausea
□ Yes □ No Distention
□ Yes □ No Hemorrhoids □ Yes □ No Heartburn
□ Yes □ No Colostomy
□ Yes □ No Ileostomy
□ Yes □ No Pain
□ Yes □ No Weight gain/loss – Reason:
How long
□ Yes □ No Vomiting
□ Yes □ No Flatus
□ Yes □ No Rectal Bleeding
____
Genitourinary: □ WNL
Color of urine
□ Yes □ No Frequency
□ Yes □ No Difficulty starting
□ Yes □ No Nocturia
□ Yes □ No Foley – Date 1c
□ Yes □ No Odor
□ Yes □ No Flank pain
□ Yes □ No Urgency
□ Yes □ No Urostomy
□ Yes □ No Burning
□ Yes □ No Incontinence
□ Yes □ No Hx of calculi
□ Yes □ No Itching
□ Yes □ No Hx UTI
Reproduc ve: □ WNL
FEMALE
LMP
G
P
□ Yes □ No Menopausal – How long?
□ Yes □ No Vaginal discharge
□ Yes □ No Hx STD exposure
Breast □ Yes □ No Do SBE Monthly?
□ Yes □ No Breast feeding
□ Yes □ No Dimpling
□ Yes □ No Itching
Last PSA
ti
□ Yes □ No Penile discharge □ Yes □ No Hernias
ti
Last PAP
□ Yes □ No Hormone replacement
□ Yes □ No Dysmenorrhea
□ Yes □ No Lumps
Last Dr. exam
□ Yes □ No Nipple discharge
□ Yes □ No Symmetry
□ Yes □ No Nipple inversion
MALE
Last prostate exam
A
□ Yes □ No Birth control
□ Yes □ No Lesions
□ Yes □ No□ Amenorrhea
Last mammogram
□ Yes □ No Family Hx
□ Yes □ No Pain
□ Yes □ No Sores
□ Yes □ No Testicular lumps
Hygiene
Breast
□ Yes □ No Pain
□ Yes □ No Lumps
□ Yes □ No Hx STD exposure
□ Yes □ No Swelling
□ Yes □ No Nipple discharge
Hematological: □ WNL
□ Yes □ No Bruising
□ Yes □ No Anticoagulant use
□ Yes □ No Anemia – Hx
□ Yes □ No Anemia – Current
□ Yes □ No Blood Transfusion – Hx
Advanced Directive
Does the patient have an Advanced Directive?
Advanced Directive form on chart? □ Yes
Additional information given?
□ Yes
□ No □ Yes – Is copy on file? □ No □ Yes – Where?
□ No – Explain
□ No – Explain
Patient Education
What does the client (patient/family) say about their learning style?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
According to your textbook, how will you teach a client with this learning style?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
How do you know this client is ready to learn?
Pt Statements:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Pt Body Language:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Intrinsic Motivators:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Extrinsic Motivators:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Pt’s Ability to learn (cognitive, physical condition, literacy, etc.):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
After reviewing all of the above, is your client ready to learn? Why or why not?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
ANALYZE
What do you plan on teaching this client? (Learning Goal)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What data did you base this decision on? (Be specific)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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What resources will you give your client?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
How will you use these resources based on your client’s learning style?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
R.N. Signature: ___________________________________________________________________________________________
Date: ________________________________________
Time: _______________________________________

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