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[1] patient's name (initials only) ________________ bed number __________ assessor: __________________________¬¬_____ interview date: _________ source of information (specify): ___________ reliability : good fair poor. birth date: __________ age: _____ gender: m. f. marital status: s m w d. if married, years married ______ number of children _______ highest level of education: _________ occupation: _______________ admission date: _________________ admitted from: _____________ medical diagnosis: _________________________________ address: _________________________ lives: alone with:_____________________ health insurance: yes no. past medical history:________________________________________________________________ past surgical history:________________________________________________________________ chief complaint(s):[2] ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ reason for admission:[2] ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ nursing diagnosis health perception and management [1] regular physical check ups: yes no. smoker: yes no. if yes, packs/day: _____ number of years _________ altered health maintenance narjileh use: yes no. if yes, frequency of use/week_______________ alcohol use: yes no. if yes, frequency/week_______ amount:______ other drugs: yes no. if yes, type, frequency, amount: _____________ safety and protection: [1] allergies (food, drug, dye, other) _____________ reaction: _______________ risk for suffocation impaired vision/hearing: yes no. mental disability ______________ risk for poisoning ambulatory devices _______ deformities ______ prosthesis _________ risk for injury blood transfusions: yes no. if yes, date: _______ reaction: _______ moving nursing diagnosis subjective [1] exercise habits (type, frequency) ________________________________ impaired physical mobility limitation(s) in mobility (specify): ______________________________ *(walking, bed mobility, fatigue weakness pain dyspnea ____________________________ * transferability) sleep: hours: ________ naps: ___________ aids: _______________ fatigue difficulty falling/remaining asleep: _____________________________ sleep pattern disturbance objective:[1] response to activity: at rest after activity (risk for) activity intolerance a- cardiovascular: hr ___________ ___________ b- respiratory: rr ___________ ___________ type of activity: ______________ other response:____________ muscle mass/tone/strength: emaciation flaccidity rigidity paralysis. posture: ______________ gait: ________________ range of motion: full other:______________________ fracture/dislocations: __________ joint problems: ___________ back problems:_______________ other: _________________ activities of daily living: subjective:[1] independent. dependent (check what applies to your client): mobility feeding hygiene dressing/grooming toileting impaired mobility other (specify): ______________________________________________ feeding self care deficit objective:[1] bathing/hygiene self care deficit body odor: ____________ presence of vermin: yes no dressing/grooming self care deficit toileting self care deficit systems i- cardiovascular subjective:[2] history of: hypertension: __________ heart disease: ________ altered tissue perfusion: rheumatic fever: _______ ankle/leg edema: ______ *cardiopulmonary phlebitis: ______________ *peripheral numbness/tingling (location):________________ chest pain (describe): _______________________________ altered comfort related to chest pain objective:[2] bp: rt: _______lt: ________ position: lying sitting standing. bp: r_________________l________________ position �lying �sitting �standing pulse pressure: _____________ nursing diagnosis pulses (palpation): carotid: ___temporal: ____ brachial: ____ radial: _____ femoral: ____ popliteal: ____ posttibial _____dorsalis pedis: ______ heart sounds: _______________________________________ heart rate: ______rhythm: regular irregular. quality: strong weak jugular vein distention: yes no. position: lying sitting. extremities: skin temperature: warm cold. capillary refill: ______ homan's sign: yes no. varicosities: ______________________ edema(specify): general dependent ascites (risk for) fluid volume excess skin: pallor: overall lips nailbeds conjunctiva skin: cyanosis: overall lips nailbeds conjunctiva ii- oxygenation: subjective:[2] dyspnea/orthopnea (describe): ________________________________ cough: productive nonproductive. hemoptysis: yes no history of: bronchitis: _________________ asthma: _________________ tuberculosis: _______________ emphysema: ______________ use of respiratory aids: _________________oxygen: _______________ objective:[2] respirations: rate:____ depth: _______ rhythm:_________ ineffective breathing pattern quality: labored unlabored. chest expansion: _____________________. accessory muscles use: yes no. pursed lip breathing: yes no breath sounds: rt upper lobe: normal decreased abnormal ___________________ lt upper lobe:normal decreased abnormal ____________________ rt lower lobe: normal decreased abnormal ___________________ lt lower lobe: normal decreased abnormal ___________________ sputum: color: _________ amount:________ consistency: thick thin ineffective airway clearance use of incentive spirometer: yes no. clubbing of fingers: yes no iii-nutrition subjective:[2] type of diet: at home: ____________ current ___________________ altered nutrition (risk for): food intolerance: yes no. if yes, describe______________________ *less than body requirement appetite changes: yes no. if yes, describe____________________ *more than body requirement nausea/vomiting: yes no. if yes, describe______________________ nursing diagnosis history of: ulcers heart burn indigestion: ____________________ altered oral mucous membranes dentures: upper lower. mastication problems: yes no. altered dentition swallowing problems: ___________________________ impaired swallowing usual weight: ________ changes in weight ( or ): _____________ risk for aspiration history of diabetes mellitus: ________________________________ objective:[2] current weight: _____ height: ______ body mass index:_________ hernia/masses: yes no. if yes, location/size:_________________ thyroid enlarged: yes no. halitosis: yes no condition of teeth/gums/tongue/mucous membranes: _____________ iv therapy: ______________________________________________ iv-elimination: - gastrointestinal/bowel subjective:[2] usual bowel patterns: frequency____ color/consistency: ________ constipation (risk for) diarrhea constipation incontinence. stoma/ostomy:yes no. diarrhea remedies used for bowel problems: _________________________ bowel incontinence history of bleeding: ________________ hemorrhoids: __________ altered comfort objective:[2] risk for fluid volume deficit bowel sounds (describe):___________________________________ abdomen tender: yes no. soft firm. liver enlarged: yes no palpable mass: yes no. if yes, describe______________________ hemorrhoids: (external): yes no - renal/urinary subjective:[2] (risk for): usual urinary patterns: times/day:_____ color_____ hematuria altered urinary elimination incontinence urgency frequency retention *incontinence pain burning difficulty voiding dribbling *retention use of aids to void:_______________________________________ history of kidney/ bladder disease: ____________________________ objective:[2] urine: color: _______ odor: _______ output/hr/shift:__________ fluid volume excess bladder palpable: yes no catheter/stoma/ostomy: yes no fluid volume deficit v- skin integrity nursing diagnosis subjective:[2] changes in moles: ________________ enlarged nodes: ____________ history of fever/infectious diseases: ____________________________ history of cancer: __________________________________________ objective:[2] temperature: ________ lymph nodes enlargement: ______________ hyperthermia skin: moist dry warm cool pale pink jaundiced hypothermia skin turgor: elastic firm fragile dehydrated impaired skin integrity skin integrity: intact. rashes: ____________ blisters: __________ impaired tissue integrity surgical incision/scar: ________________ ecchymosis: ______________ (risk for) lacerations: ________________________ ulcerations: _______________ risk for infection pressure sores: _________________________________________________ cognitive /perceptual subjective:[2] history of: fainting/ syncope:___________ dizziness:___________ headaches: location___________ frequency _________________ stroke _____________________ seizures ____________________ sensory/perceptual disturbance: vision: no problem deficit: right left. glasses lenses *visual hearing: no problem deficit: right left. hearing aid *auditory smell: no problem deficit:__________________________ *olfactory taste: no problem deficit:__________________________ *gustatory objective:[2] level of consciousness (check what applies to your patient): altered thought processes alert drowsy stuporous comatose restless/agitated orientation: time: yes no. place: yes no. person: yes no. loss of memory: recent: yes no. past: yes no. impaired memory pupils: equal size: yes no. if no, describe:_________________ pupil reaction: -direct: brisk: rt lt. sluggish: rt lt. non reactive: rt lt. -consensual: brisk: rt lt. sluggish: rt lt. non reactive: rt lt. facial droop: rt lt. gag reflex: present absent handgrasp: rt: __________________ lt: ___________________ deep tendon reflexes:___________________________________ nursing diagnosis verbal response: clear slurred unintelligible aphasic impaired verbal communication gait disturbance � yes � no paralysis (describe)_________________________ feeling a-pain subjective: [2] pain: yes no. pain onset: __________location: _________ radiation: __________ intensity (1-10): ______ quality: ________ frequency:_______ duration: _____ associated with: _________________________ aggravated by: ________________ alleviated by: ___________ objective:[2] facial grimacing: yes no. guarding affected area: yes no. emotional response to pain: crying withdrawn angry b-psycho-socio-cultural emotional integrity: subjective:[1] recent stressful life events other than illness: yes no. if yes, describe:____________________________________ how do you usually manage stress?____________________ objective:[1] emotional status (check those that apply): anxiety calm cooperative anxious angry withdrawn fear combative irritable euphoric other_____________________ grieving associated physical manifestations:__________________________ impaired social interaction role:[1] role within family: breadwinner caregiver other__________ altered role performance how does your illness affect your: family____________________________________________ job_______________________________________________ valuing:[1] does illness/hospitalization interfere with any of the following: 1. religious practices: yes no. _________________________ 2. cultural practices: yes no. __________________________ 3. family traditions: yes no. ___________________________ sexuality/reproduction nursing diagnosis female subjective:[1] age at menarche: ____ length of cycle: _____ duration: ________ last menstrual period: _______________ menopause: yes no. vaginal discharge: __________ bleeding between periods: : yes no. altered sexuality patterns practices breast self-examination: ______ last pap smear: _________ history of std: __________________________________________ sexual concerns/problems:___________________________________ objective:[1] breast examination: ______________________________________ vaginal warts/lesions: _____________________________________ male [2] penile discharge: _____________ prostate disorder: _____________ practices self-examination: breast: __________ testicles: ________ last prostate exam: _____________ history of std:________________________ sexual concerns/problems: _________________________________ knowing [1] familial history (specify which relative has the disease): anemia/blood dyscrasias ___________ peripheral vascular ____________ cancer _________________________ kidney disease _______________ diabetes ________________________ stroke ______________________ heart disease _____________________tuberculosis _________________ hypertension _____________________ other: ______________________ knowledge about current illness: ________________________________ knowledge deficit ___________________________________________________________ knowledge about current medications/treatments: ___________________ ___________________________________________________________ expectations of therapy: _______________________________________ requesting information concerning: _________________________________ list the nursing diagnoses identified to your client in priority order: 1. ______________________________________________ 2.______________________________________________ 3.______________________________________________
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