NEW YORK UNIVERSITY COLLEGE OF NURSING

NURSING ASSESSMENT FROM – For Adult-Elder I Clinical (LTC/Nursing Home)

STUDENT’S NAME: ___________________________ CLINICAL UNIT: ____________________________

DATE OF PATIENT CARE ______________________ CLINICAL INSTRUCTOR _____________________

I. DEMOGRAPHIC DATA:
Patient Initials: _______ Age: _____ Gender: ______ Date of Admission __________ Advance Directives ______________

HISTORY OF PRESENT ILLNESS:

Reason for admission to the LTC facility - (“what brought you to the Nursing Home?” – must include “What happened, where,
when, how long prior to admission)

DIAGNOSIS: –

ALLERGY: – DESCRIBE REACTION(S): ________________________

I. PAST MEDICAL/ PSYCHIATRIC HISTORY (Include date condition was diagnosed, if known):

II. PAST SURGICAL HISTORY (include dates of surgery, if known):

III: PSYCHOSOCIAL HISTORY:

Spiritual/ Cultural Assessment: Religion_______________ Cultural/Ethnic background ____________ Marital status________
Smoking – yes cigarettes/day ____ no
Influenza Vaccination – yes Date: _______ no Pneumovax – yes Date_________ no Reason _____________
Discharge Planning:
Support Systems: _________________________________________________________________________________________
Living arrangements_______________________ Caregiver______________ Referral Needs___________________________
Medication Compliance Issues (literacy/language barrier etc.): _____________________________________________________

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IV. VITAL SIGNS and PAIN ASSESSMENT

BP ________ Apical Heart Rate (rhythm) ______________ Radial (rate/rhythm) _____________ Resp. Rate and Pattern __________
Temperature ________ Pulse Oximetry _______ Height __________ Weight ___________ BMI____________

Time Location of Pain Scale Interventions Scale Comments

(Pre) (Post)

V. PHYSICAL ASSESSMENT / SYSTEMS REVIEW

1. Neurological System:
Subjective Data: __________________________________________________________
[ ] Alert [ ] Confused [ ] Lethargic [ ] Restless [ ] Aphasic Orientation [ ] Time [ ] Place [ ] Person
Other neurological findings: _____________________________________________________________________________

2. Neuromuscular System:
Subjective Data___________________________________________________________
[ ] Intact motor & sensory function [ ] Weakness – [ ] right, [ ] left [ ] Paralysis – [ ] right, [ ] left
Gait: [ ] steady [ ] Unsteady Use of Assistive device: [ ] Cane [ ] Walker [ ] Wheelchair
Other neuromuscular findings___________________________________________________________________________

3. Cardiovascular:
Subjective Data: ______________________________________________________________________
[ ] Chest Pain (describe) _________________________________________________________ [ ] Palpitations
Peripheral Pulses Dorsalis Pedis [ ] Present [ ] Weak [ ] Absent Posterior Tibialis [ ] Present [ ] Weak [ ] Absent
Other cardiovascular findings: ___________________________________________________________________________

4. Respiratory:
Subjective Data: ______________________________________________________________________
RR _________ Pattern: [ ] Regular [ ] Irregular Use of accessory muscles [ ]
Breath sounds [ ] Clear, bilateral [ ] Abnormal/ Presence of adventitious sounds [ ]

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 [ ] O2 therapy _____________[ ] Cough productive yes [ ]describe ____________ no [ ]
Other: _____________________________________________________________________________

5. Gastrointestinal:
Subjective Data: _____________________________________________________________________
Abdomen: [ ] Soft [ ] Firm [ ] Distended [ ] Tenderness [ ] Bowel sounds: [ ] Present [ ] Diminished [ ] Absent
[ ] Nausea [ ] Vomiting [ ] Anorexia [ ] NGT/OGT/PEG feeding formula/rate ___________________________________
Residuals (color/Amount) ___________________________
[ ] Last BM (Date) __________ [ ] Constipation [ ] Diarrhea # times________ Type of Stool ________ Onset________
[ ] Ostomy (specify ________________________ Dental/Oral Health (describe) ___________________________________
Other GI findings: ______________________________________________________________________________________

6. Genitourinary:
Subjective Data: ________________________________________________________________________________________
Urine Color_________ Character_____________ [ ] Voiding [ ] Foley catheter – date inserted ____________________
[ ] Incontinence [ ] Dysuria Other GU findings: ____________________________________________________________

7. Integumentary:
Subjective Data: ________________________________________________________________________________________
Skin quality: Temperature [ ] cool, [ ] warm [ ] Dry [ ] Moist [ ] Ecchymosis [ ] Hematoma [ ] Petechiae
[ ] Edema (indicate location) _______________________________________ [ ] Rash [ ] Scar _________
[ ] Pressure ulcer site____________________________________________________________________________________
Braden Scale Score ________ [ ] Operative wound (describe) ___________________________________________________
Other Integumentary findings_______________________________________________________________________________

VI- List of Medications the resident is taking each day.

VII - LIST THREE (POTENTIAL AND ACTUAL) PATIENT CARE NEEDS/CONCERNS:

1.

2.

3.

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