Student:

__

Client'sInitials
__ _________________
MedicalDiagnosis

Date:

_____________________
DateofAdmission:
Nursing II Assignment ASSESSMENT(DATACOLLECTION)

Spring 2008
PHYSIOLOGICAL:
OXYGEN:Cardiovascular
Skinwarmtotouch?
Skincolor
Colorofnailbeds
Temperature
Location
Radialpulserate
Rhythm
Apicalpulserate
Rhythm
BP:Location
Position
PeripheralPulse
Pulseox

Respiratory
Respiratoryrate
Rhythm
Audiblebreathsounds
Dyspnea atrest
onexertion
Cough
Sputum
None
Smokes
Packsperday
* Medications
Laboratorydata
Equipmentinuse(O2, flowrate)

PainScale#NU
Capillary Refill

Additionaldata:

FA

FLUIDSANDELECTROLYTES:
Skinturgor Normal
Poor
Presenceofthirst
Tongueandlips
Nauseaorvomiting
Mucousmembranes
Presenceofedema
Fluidintakeforprevious24hrs
*Medications
Fluidrestriction
(Noteamtq224hrs&distribution
qshift)
Laboratorydata
Equipmentinuse
Additionaldata:

NUTRITION:
Ht
Wt
Ordereddiet
Preferredfoods
%ofmealconsumed
Dietarysupplement
Assistancewithmeals

none

Dentures? Upper
Lower
Partial
Recentchangeinweight?
Problemchewing?
Swallowing?
Heartburn?
*Medications
Laboratorydata
Equipmentinuse(N/Gtube,PEGtube,Gtube,etc.)
Additionaldata:

ELIMINATION:
Urinary:
Bowelsounds
Amount
Color
Frequency
*Medications
Bathroom
Commode
Bedpan
Incontinent
Laboratorydata
Totaloutputforprevious24hrs
ml
Equipmentinuse
Bowel:Amount
Color
Frequency
Additionaldata:
Normalforclient
Constipated
Diarrhea
Incontinent
MOBILITYANDACTIVITY:
Musclestrength Handgripsequal
Footpushesequal
ROM Normal
Limited
Severelylimited
Abilitytomoveinbed Self
Assist
Immobile
OOB Chair
Wheelchair
Gerichair
Abilitytotransfer Self
Assist
Distanceabletoambulate
Gait
REST,SLEEPANDPAIN:
Reportedqualityofsleepinhospital
C/OPain

some,doesnotdrinkwater

Indigestion?

Abdominaldistention

FallAssessmentScore
Fallrisk High
Moderate
Low
Physicaltherapyworkingwithclient?
*Medications
Laboratorydata
Equipmentinuse(assistivedevices)
Additionaldata:

Observablesignsofpain Grimacing
Posturing
Moaning
*Medications_____________________________________________

Location
Intensity
Duration

PainScale#NU
Additionaldata:

FA

SAFETYANDSECURITY:
Vision:Skinintegrity:
Abletoseewithoutglasses
Needsglasses
Intact
Abletoreadownmenu
Reddened
Location
WatchesTVfrom
ftBlancingerythema
Nonblancingerythema
*Medications
Incision/Lesion/Wound
Location
Approx.sizeincms
Hearing:Appearance
Respondstonormalvoicetones
Treatment(dressings,etc.)
Hearingaid
Deaf
*Medications
Speech:Allergies
Clear
Garbled
Incomprehensible
Laboratorydata
Mentalstatus:Environment:
Alert
Lethargic
Unresponsive
Physicalsurroundings
Orientedto Person
Time
Place
*Medications
*Medications
Additionaldata:
Braden/NortonScore#
Risk:High
Moderate
Low

LOVEANDBELONGING:
Clientreportoffamily/friends
Indicators Cards

Flowers

Nextofkin(chart)
Religiousaffiliation
Additionaldata:

Familypictures

SELFESTEEM:
Familyrole
Occupation
appearance

Groomingequipmentatbedside:
Brush/comb
Toothbrush
Otherpersonaltoiletries
Additionaldata:

SELFACTUALIZATION:
Clientreportofsatisfactionwithlife

Additionaldata:

Independence
Creativity
ERIKSON=SSTAGEOFDEVELOPMENT:
Theclientisatthefollowingdevelopmentalstageandexplainwhy:

*Alwaysincludenameofmedication,dose,routeandtime.
assessmentNSGIISpring08

Toothpaste

Interestin