Langston University

NR4423 & 4426

Patient Assessment Sheet
Students Name
Clients Initials

Area/Unit
Age

Date of care

Ethnicity ____________ Male ____ Female ____

Support Person (Initials/Relationship)

Marital Status

Medical Diagnosis_________________________________________________________
Allergies

Reaction
___________________________________________

Reaction ________________

____________________________________ Reaction ________________

____________________________________ Reaction ________________
____________________________________ Reaction ________________
Latex: No Yes

Reaction __________________________________________

Current Medications (Include over the counter (OTC), Herbs, and Vitamins
Drug
Dose
Frequency

Vital Signs
Tim Blood
e
Pressure

Te
mp

Puls
e

Res
p

Pai
n

Pulse
Ox

Langston University
NR4423 & 4426
Patient Assessment Sheet

Lab Work
Lab/Test

Low
Normal
High

Results

Normal Range

Implications
(ie: What is the purpose of the test and what is
its importance?)

Current Lab Results **** Low (L), Normal (N), High (H)

Health Perception/Health Management

How does client describe health in past? ________________________
Describe specific complaints/concerns: _________________________
How does client describe health at this time?_____________________
What does client do to keep healthy? ___________________________
Average # alcoholic drinks/week ____________________
Smokes Packs/day ________ # of years ____________
Quit: Date __________

# of pks/yrs ____________

Drugs: Type ____________ Frequency ________________

Significant Family Health Hx:____________________________
___________________________________________________
Recreational Drugs:
Type ___________________ Frequency ________________
Type __________________ Frequency ________________
Type __________________ Frequency ________________
Past Medical and Surgical
Hx:____________________________________________

Additional Comments
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Nursing Diagnosis Cues

Health-Seeking Behavior
Ineffective Therapeutic
Regimen
Knowledge Deficit
Risk for injury

Immunizations:__________________________________

Langston University
NR4423 & 4426
Patient Assessment Sheet
Nutrition/Metabolic
Additional Comments
_________________________
_________________________
Wt: Current _______________ Ht _________________
_________________________
Significant wt changes___________________________
_________________________
Skin color ___________ Skin Temp. ___________ Turgor __________
_________________________
Edema: 0 +1 +2 +3 +4 Pitting
_________________________
_________________________
Location ______________________________________________
_________________________
Bruise
Laceration
Rash
Scar
_________________________
Location/Describe: ________________________________________________ _________________________
_________________________
Incision Staples Sutures Open to air Dressing
_________________________
_________________________
Describe: _________________________________________________
_________________________
Intake/Diet ________________________________________________
_________________________
Nausea
Vomiting
Reflux
Heartburn

_________________________
Pain
_________________________
_________________________
Swallowing:____________________________________
_________________________
Appetite:______________________________________
_________________________
Describe above responses ___________________________________
_________________________
IV Fluids (list) ___________________________ Rate ______________
_________________________
IV Site (describe) ___________________________________________ _________________________
_________________________
Diabetes Diet controlled Medication: Type ________________
_________________________
Dose ______________ Frequency _____________
_________________________
_________________________
Metabolic Disorder (specify) ________________________________
_________________________
Preferences/Restrictions _____________________________________
_________________________
Food Allergies:
_________________________
_________________________
Food __________________ Reaction ________________________
_________________________
Food __________________ Reaction ________________________
Food __________________

Reaction ________________________

Food __________________

Reaction _______________________

Elimination
Urination: Usual # voids/day _____________ Problems
________________
Burning Hematuria Urgency Retention Renal Disease
Dysuria
UTI (specify #/when)
_____________________________________________
Incontinence (when/factors)
_________________________________________
Appearance: Color ________ Clarity ___________ Odor ________
Catheter
Bowel: Usual # BMs/day _____________
Last BM________________________

Additional Comments
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Nursing Diagnosis Cues

Impaired Skin Integrity
Risk for Fluid Volume
Imbalance
Knowledge Deficit
Ineffective Therapeutic
Regimen
Risk for Infection
Nutrition, Imbalance:
Less than body req.
More than body req.

Nursing Diagnosis Cues

Constipation
Diarrhea
Impaired Urinary
Elimination
Urinary Incontinence

Langston University
NR4423 & 4426
Patient Assessment Sheet
_________________________
IBS/Colitis Diverticulitis Hemorrhoids Diarrhea, freq:
_________________________
______________ Constipation Aids (specify)
_________________________
_______________________________________
Changes in bowel pattern/appearance (describe)
________________________
Bowel sounds: X4

Hyperactive

Hypoactive

Absent

Flatus

Distention Pain Tenderness

Describe __________________________

Activity/Exercise
HX: Asthma HTN

Other ___________________

Usual Daily Activities ________________________________________________

_________________________________________________________________
Heart Sounds: ____________________________________________________
Peripheral Pulses: Indicate pulse rate
Radial

_________ R

Apical

_________

__________ L

Rhythm____________________

Ectopy_______________

Capillary Refill: Measure in seconds

Upper extremities _________ R

__________ L

Breath Sounds: Clear to Auscultation (CTA ) Location_________________

Adventitious,
Describe:__________________________________________________________
_________________________________________________________________
_________________________________________________________________
Pulse Ox __________%

Room Air (RA)

O @ _________l/pm

By Mask____ By Nasal Cannula ___

Ventilator
ET Tube:

cm @ lip

Ventilator Mode:

Rate:

Tidal Volume:

FiO2:

% Titrate: Yes/No

PEEP:

Weaning? Outline Parameters

Sedation/Chemical Restraint:
1.

mL/hr

2.

mL/hr

Concentration:

Concentration:

Mobility: (BR) Bed rest (BRP) Bathroom Privileges

Ambulation Restraint location____________________________

Mobility Aids
Walker

Cane

Crutches

Wheelchair

Additional Comments
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Nursing Diagnosis Cues

Activity Intolerance

Ineffective Airway Clearance

Self Care Deficit

Impaired Physical Mobility

Risk for Injury

Activities of Daily Living (ADL): Independent Dependent

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Risk Factors for Falls: _______________________________________________

Langston University
NR4423 & 4426
Patient Assessment Sheet
Sleep/Rest Pattern

Stay asleep?

Hours sleep/night:
Naps? Feel rested?
Awaken during night?
Insomnia?
Methods to promote sleep:

Self Care Ability Rating

Independent
Assistive device needed
Assistance from others needed
Assistance from people/equipment
Total dependence

0
1
2
3
4

Cognitive/Perceptual
Neuro Hx: Seizures Fainting Numbness/Tingling Weakness
Headache
Illness/Treatment:_______________________________________
_________________________________________________________________
Level of Consciousness (LOC): _____________________
Deep Tendon Reflexes (DTR):
Rt ___________
Lt ___________

Site __________________
Site__________________

Reflexes:
Cough
Gag
Corneal
Hand grasp:
R
L
Pedal push/pull:
R
L
Visual Disturbances (describe): ________________________________________
Vision: Glasses Contacts Last Vision Check: _______________________

Home Maintenance
Transferring
Eating
Ambulating
Bathing
Stairs
Dressing
Shopping
Toileting
Cooking
Bed Mobility
AVERAGE
Additional Comments
Nursing Diagnosis Cues
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_________________________ Pain
_________________________
_________________________ Impaired communication
_________________________
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_________________________ Knowledge Deficit
_________________________
_________________________ Confusion
_________________________
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_________________________ Sensory perception,
_________________________ Disturbed (Visual, Auditory,
_________________________ Kinesthetic, Tactile,
_________________________ Olfactory)
_________________________
_________________________ Thought Process ,
_________________________ Impaired
_________________________
Memory, Impaired

Hearing: R ______ L______

Language/Speech Deficit: _____________________________________
Need for Translator__________________________________________
Learning Style: Visual

Auditory

Tactile/Kinesthetic

Pain/Discomfort: Level (0-10) __________________

Location/Type _____________________________________________________
Pain management (describe): _________________________________________
_________________________________________________________________
Effectiveness: _____________________________________________________
_________________________________________________________________

Glascow Coma score:

Langston University
NR4423 & 4426
Patient Assessment Sheet
RAAS:

Sleep/Rest
Hx: ___________ Hrs/night

Naps

Awaken rested, prepared for day

No, describe:
_____________________________________________________
_________________________________________________________________

Hx: Sleep aids _____________________________________________

Current factors affecting sleep: ________________________________
_________________________________________________________
_________________________________________________________
Expected factors/adaptations: _________________________________

Self Perception/Self Concept

Affect/Mood (describe): ______________________________________
Body Language (describe): ___________________________________
Eye Contact: Yes No, describe: ___________________________
Personality type:___________________________________________
Developmental Stage: _______________________________________
Theorist: Havighurst __ Sullivan __ Freud __ Piaget __ Erickson __
Objective Support: _________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Role/Relationship
Married Single Divorced Other ____________________
Children, how many __________________________
Present living situation:_____________________________________
_______________________________________________________
Plans to return to same living arrangement: Yes No,
describe new arrangement: ________________________________
______________________________________________________
Help at home (describe): _____________________________________
_________________________________________________________
Type of work: ______________________________________________
Employment status: Full time___ Part time ___ Volunteer ___
Job satisfaction: ____________________________________________
Plans for the future: _________________________________________
_________________________________________________________
_________________________________________________________
Observed Leadership/Family
Roles:___________________________________________________

Additional Comments
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Nursing Diagnosis Cues

Sleep pattern disturbance

Additional Comments
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Additional Comments
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Nursing Diagnosis Cues

Self-esteem disturbance
Body Image disturbance
Risk for loneliness
Powerlessness
Self-esteem, Disturbance

Nursing Diagnosis Cues

Social Isolation
Ineffective
Individual/Family Coping
Ineffective Role
Performance

Communication, Impaired
verbal

Grieving, Anticipatory

Langston University
NR4423 & 4426
Patient Assessment Sheet
Roles:___________________________________________________
_________________________
_________________________
Roles:___________________________________________________
Sexuality/Reproductive
Concerns/expectations regarding :sexuality: _____________________
_________________________________________________________
Concerns Regarding sexual performance________________________
_________________________________________________________
Sexually Transmitted Diseases ________________________________
________________________________
________________________________
Planned Contraception ______________________________________

Additional Comments
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Nursing Diagnosis Cues

Additional Comments
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Nursing Diagnosis Cues

Ineffective Individual
Coping/Family Coping

Additional Comments
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Nursing Diagnosis Cues

Sexual Dysfunction
Risk for Infection
Body Image Disturbance

MALE
FEMALE
Last Exam:

Coping/Stress
Major Change(s) in last year: ________________________________
________________________________________________________
________________________________________________________
Concerns :Financial____ Social ____ Job _____ Parenting___
Concerns with Relationships:
Children __________________________________
Extended Family____________________________
Spouse ___________________________________
Observed physiological/behavioral response to stress (describe):
_________________________________________________________
Coping behaviors:__________________________________________
_________________________________________________________
_________________________________________________________

Value/Belief/Culture
Spiritual/religious requests/preferences: _________________________
_________________________________________________________
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Cultural considerations/ preferences: ___________________________
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Anxiety
Readiness for Enhanced
Family Coping

Spiritual distress

Anxiety

Readiness for Enhanced

Spiritual Well-being

Langston University
NR4423 & 4426
Patient Assessment Sheet
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