BASIC ASSESSMENT NURSING 1461

BASIC ASSESSMENT

NURSING 1461

SAFETY

CLINICAL OBSERVATION/NARRATIVE NOTES

ID band allergy band side rails

bed position call light fall precautions

Environment/Comments/Patient=s Understanding of Safety

COMFORT/PAIN

comfort assessed

pain

; location(s)

onset

; duration

initiating factors

alleviating factors

quality

intensity

pain management

Pain Scale: 0 - 10

0 1 2 3 4 5 6 7 8 9 10

none mild

moderate severe

Diagnostic/Lab Studies:

Nursing Diagnosis:

Therapeutic Modalities: Teaching Needs:

NEUROLOGICAL

Level of Consciousness

alert _____ stuporous _____

awake

comatose _____

lethargic

Orientation/Communication O x 3: person place time affect (mood) speech: clear _____ mumbles _____ aphasic _____ response to simple commands response to pain unresponsive

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(Neurological, continued)

Pupil Size/Response (PERRLA)

Right: size

equal

shape

reaction: brisk

sluggish _____

fixed _____ accommodation

Left: size

equal

shape

reaction: brisk _____ sluggish _____

fixed _____ accommodation

CLINICAL OBSERVATION/NARRATIVE NOTES

Diagnostic/Lab Studies: Nursing Diagnosis:

Therapeutic Modalities: Teaching Needs:

SENSORY

Eyes

clear

red

jaundice

drainage

vision

____________________

glasses

contact lenses

blurred vision

dyplopia

_____

scotoma

Ears assessment of hearing ____________________ drainage ____________________________ tinnitus __ vertigo ______

Sensation numbness _____ tingling _____ location ___________________________

Diagnostic/Lab Studies:

Therapeutic Modalities: Teaching Needs:

Nursing Diagnosis:

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RESPIRATORY/PULMONARY

CLINICAL OBSERVATION/NARRATIVE NOTES

Shape of Chest

symmetrical

asymmetrical ___ barreled ___

Movement of Chest

symmetrical

asymmetrical _____

Rate/Pattern

rate/min

depth

eupnea _____

dyspnea _____ shortness of breath ______

labored breathing _____

Breath Sounds

(auscultate bilaterally)

(anterior/posterior)

vesicular

bronchovesicular

bronchial __

clear

moist _____ crackles (rales) _____

rhonchi _____ wheezes _____

normal _____ diminished _____

location of abnormal sounds

_______

Cough/Sputum Observations

cough _____ unproductive _____ productive

color __________________

characteristics:

thin _____ tenacious

purulent _____

frothy _____ amount

Skin Color (oxygenation/tissue perfusion) normal for ethnic group _____ pallor _____ ashen _____ dusky _____ cyanotic _____ ruddy _____

Supplemental Oxygen

02 _____% _____liters/min __________ nasal cannula _____ mask _____

humidified _____

Diagnostic/Lab Studies:

Therapeutic Modalities: Teaching Needs:

Nursing Diagnosis:

109

CARDIOVASCULAR

CLINICAL OBSERVATION/NARRATIVE NOTES

Vital Signs

BP

apical pulse

radial pulse _____

range

range

range

Heart Sound(s) S1, S2

clear

irregular _____

regular

extra sounds _____

Peripheral Pulses Sites __ __ ____________ ____________

Scale

R

L ______

R

L ______

R

L ______

R _____ L ______

(scale: 0-4) 0 = 1 = 2 = 3 = 4 =

absent thready weak normal bounding

Perfusion

skin warm

cool ____ dry

moist ____

clammy _____

skin color normal for ethinic group

pale _____ pallor _____ mottled _____

Capillary refill 3 sec sluggish _____

Homan=s sign positive _____ negative ______

Edema location ______ dependent ____ generalized ___ pitting: (scale/picture)

+1 (2 mm.) +2 (4 mm.) +3 (6 mm.) +4 (8 mm.)

Therapeutic Modalities:

DTR __________

Clubbing of Nails Diagnostic/Lab Studies:

Teaching Needs:

Nursing Diagnosis:

110

GASTROINTESTINAL

CLINICAL OBSERVATION/NARRATIVE NOTES

Mouth (lips, gums, tongue, throat)

dry

pink

reddened ____

moist

pale ____

cyanotic

soreness

odor _____

mucous membrane: intact

broken _____

difficulty swallowing ______

Teeth missing teeth

edentulous

dentures ____

condition of teeth _____ difficulty chewing ______

Abdomen round soft scars ostomy

flat

pendulous ____

firm

distended ____

location(s) ________________

type __________

Bowel Sounds x 4 Quadrants

hypo-/hyperactive ______

Nausea/Emesis nausea ________ color __________ frequency ______

emesis _________ amount _________ onset ___________

Stools

last BM

continent

incontinent _____

amount ______ constipation

diarrhea _____

color

formed

semi liq _____ liq _____

hemorrhoids _____ colostomy _____

Weight

present weight

IBW ______

OB: pre-pregnant ______

Therapeutic Modalities:

Appetite

type of diet ________________________

good

fair

poor ______

% eaten ______

intake _____

NG feeding type

alternative nutrition type

amount ____________ amount ____________

recent wt loss

gain _____ # lbs

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