Académique Documents
Professionnel Documents
Culture Documents
INDEPENDENT STUDY
Nurs460 Spring 2010
Has received blood in the past? Yes _____ No ______ if yes, list dates_________________
Allergies:
Food: ______________________________________________________________________________
Medications: _________________________________________________________________________
Additional Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
A. DIGESTIVE/METABOLIC/NUTRITION
1
Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.
Objective Subjective
General Appearance: □ Alert/responsive Usual Diet: ___________________________________
□ Apathetic □ Cachexia □ Abdominal Distention No. of meals per day: ___________ (3x a day)
No. of fluid drink each day: _______(8-12 glasses/day)
□ Mass □ Tenderness/pain
Skin: □Dry □Warm □Cold □Moist □Edema
□ Alcohol and Beverages ________________________
Turgor: ____________________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
B. RESPIRATORY SYSTEM
2
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective Subjective
Breath Sounds: □ Diminished/Absent □ Stridor Previous/Recent Illnesses:
□ Rales/Crackles □ Rhonchi/Wheezing □ Bronchitis □ Emphysema □ Asthma
□ Normal (Vesicular, Bronchovesicular, Bronchial) □ Brochiectasis □ Pneumonia □ Hydrothorax
□ None (atelectasis) □ Pneumothorax □ Hemothorax □ CHF
□ Chest Trauma □ Lung Cancer
Resonance: □ Hyper □ Hypo Comment: ____________________________________
_____________________________________________
Respiration/Oxygenation: _____________________________________________
□ Normal(Relax, Effortless and Quiet) _____________________________________________
□ Labored/Use accessory Muscle] □ Dyspnea
□ Tachypnea □ Bradypnea □ Cyanosis Breathing Treatments/Medication: ______________
□ Pallor □ Cheyne-stoke □ Biot’s _____________________________________________
□ Hyperventilation □ Hypoventilation _____________________________________________
□ Nasal Flaring □ Pursed lip □ Barrel Chest _____________________________________________
□ Pleuritic Pain
Smoking:
□ O2 Inhalation _____liters/min
Rate: ________________________ □ Yes For how long: __________
Tube/Drainage: □ CTT □ Oral Airway □ No
Comment:____________________________________
□ Endotracheal Tube □ Ventilator
_____________________________________________
_____________________________________________
Cough: □ Productive □ Non-productive _____________________________________________
Sputum: □ Mucoid □ Bloody (hemoptysis) _____________________________________________
□ Rusty □ Frothy □ Thick Tenacious
Color: ____________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
C. CARDIOVASCULAR/CIRCULATORY SYSTEM
3
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective Subjective
Temperature: _______________ Celsius Previous/Recent Illness:
Blood Pressure: Right_______ Left ___________ □ CVA □ CHF □ MI □ Thrombophlebitis
□ Family History of HPN □ Renal Failure
Pulses:
Carotid Pulse: □ Thready □ Weak □ Strong □ Absent
□ Bleeding Disorder __________________________
Rate: Right______Left______ Comment: ____________________________________
_____________________________________________
Apical: □ Regular □ Irregular Rate: ____ _____________________________________________
_____________________________________________
Radial Pulse: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right______ Left _______
_____________________________________________
Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak Do you experience any of the following:
□ Strong □ Absent Rate: Right_____ Left _____
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak
□ Chest pain □ Arm pain □ Leg pain
□ Strong □ Absent Rate: Right_____ Left _____ □ Joint and Back □ Dyspnea □ Orthopnea
□ Cough □ Numbness and Tingling
Heart Rhythm: □ Tachycardia □ Bradycardia □ Light headedness □ Fatigue and weakness
□ Arrhythmia/ Dysrhythmia □ Palpitations
Comment: ___________________________________
Jugular Veins Distention: _____________________________________________
□ Positive □ Negative _____________________________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
D. INTEGUMENTARY SYSTEM
4
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective Subjective
Skin: □ Dry □ Intact □ Warm □ Cold □ moist Comment : ___________________________________
Turgor:_____________________________________ _____________________________________________
□ Pallor □ Cyanosis □ Jaundice □ Rashes _____________________________________________
_____________________________________________
□ Acanthosis Nigricans □ Albinism □ Erythema
_____________________________________________
□ Edema □ Petechia □ Itching □ Drainage _____________________________________________
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer Comment:____________________________________
Temperature: _________ _____________________________________________
_____________________________________________
Hair: □ Alopecia □ Hirsutism □ Patchy hair loss
Distribution: ________________________________ Comment:____________________________________
_____________________________________________
Nails: □ Dirty □ Pallor □ Cyanosis _____________________________________________
_____________________________________________
□ Clubbing □ Paronychia □ Onycholysis
Capillary refill: __________ (Normal less than 2 sec)
Color: _________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
E. ELIMINATION
5
Objective Subjective
Mobility and Dexterity: Previous/Recent Surgery/Illness:
□ Ambulatory □ Non-ambulatory _____________________________________________
□ Bedridden □ with assistive device
History of pain and discomfort: _________________
Tubes/Drainage/Stoma: _____________________________________________
□ Colostomy □ Ileostomy □ NGT
Diet: ________________________________________
□ Catheter □ Suprapubic Catheter
Personal Elimination Habits:____________________
Abdomen: □ Soft □ Firm _____________________________________________
□ Distended □ Non-distended
Elimination Problem:
Bowel Sounds: (5 – 20 sounds/min) □ Loose bowel movement _________
□ Normoactive □ Hypoactive □ Constipation □ Impaction □ Fecal Incontinence
□ Hyperactive(Borborygmi) □ Absent □ Neurologic Impairment □ Dysuria □ Urgency
□ Polyuria □ Oliguria □ Nocturia □ Dribbling
Measurement:
□ Incontinence □ Hematuria □ Retention
Intake ____________ Output:_______________
□ Discharge
Edema: □ Yes □ No □ Residual urine (> 100ml)
Location: __________________________________ Comment: ___________________________________
_____________________________________________
Present Urine Color: ________________________
Medication taken: □ Analgesic Narcotic
Note: Assess urine frequency, color, odor control, □ Antibiotics □ Anticholinergic □ NSAID
comfort/gyn-bleeding, discharge. □ Aspirin □ H2 antagonist
Comment: Fluid intake per day: __________ liters/day
__________________________________
___________________________________________ Physical Activity: _____________________________
___________________________________________ Comment: ___________________________________
___________________________________________ _____________________________________________
___________________________________________ Excessive Perspiration and Odor Problem:
___________________________________________ □ Yes □ No
___________________________________________
Consistency:_________________________________
Stools: ______________________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
F. MUSCULOSKELETAL SYSTEM
6
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.
Objective Subjective
Mobility: □ Ambulatory □ Non Ambulatory Do you experience any of the following:
□ Bedridden □ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Appliance __________________________ □ Joint pain
Gait and Posture: □ Lordosis □ Kyphosis Comment ____________________________________
_____________________________________________
□ Scoliosis □ Shaftling □ Poliomyelitis
_____________________________________________
□ Amputated Limb ______________________
Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
□ Contractures/Deformities □ Crepitus Comment: ___________________________________
□ Tingling/Numbness (Carpal Tunnel Syndrome) _____________________________________________
_____________________________________________
□ Ankylosis □ Foot Drop □ Pressure Ulcers
_____________________________________________
□ Urinary Elimination changes _________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Reflexes:
Patellar □ Positive □ Negative
Biceps □ Positive □ Negative
Triceps □ Positive □ Negative
Achilles □ Positive □ Negative
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________