TVCC



TRINITY VALLEY COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING

PATIENT ASSESSMENT

Level I & II & Transition

|Student’s name: | | |Nursing diagnoses with |

| | | |priority designation: |

| | | |H – High |

| | | |M – Moderate |

| | | |L - Low |

|Patient’s initials: | |Age| |

| | |: | |

|(Admitting, Plus ALL other medical diagnoses) | | |

|HEALTH HISTORY: (SUBJECTIVE DATA) | | |

|Chief complaint: Use patient’s own words. | | |

| | | |

| | | |

| | | |

|Pathophysiology: Include a referenced pathophysiology of the primary medical diagnosis(es). Include the | | |

|underlying disease process, affected organs, signs and symptoms, and complications. Note: if the patient has | | |

|other diagnoses, a referenced pathophysiology must be completed on each. | | |

| | | |

|History of Present Illness (HPI): Include 8 variables of: body location, quantity, quality, chronology, | | |

|setting, aggravating & alleviating factors, and associated manifestations. | | |

| | | |

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| | | |

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|Past Medical History (PMH): | | |

|How do you rate your health? Poor, Fair, Good, Excellent (circle one) | | |

| |General health and strength: (Describe) | | |

| | | | |

| | | | |

| |Health maintenance activities: | | |

| |a. Last physical examination | |b. | |

| | | |Usu| |

| | | |al | |

| | | |sou| |

| | | |rce| |

| | | |of | |

| | | |hea| |

| | | |lth| |

| | | |car| |

| | | |e | |

| |d. Routine health screening: (BSE, TSE, mammogram, PSA) | | | |

|Home Medications: (prescription, nonprescription, vitamins, supplements, herbs, eye drops, birth control | | |

|method, etc. | | |

| |Medication | | |

| |Dosage | | |

| |Frequency | | |

| |Reason | | |

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|Allergies: (to medications, food, and environment) Describe type of reaction | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| | | | |

| | | | |

|Any adult illnesses and/or pertinent childhood illnesses? | | |

| | | | |

|Surgeries: | | | |

|Hospitalizations: | | | |

|Immunizations: | | | |

| |Any exposure to contagious illnesses? | | | |

|Trauma: | | | |

|Transfusions: | | | |

| | | |

|Family History: (Identify the family member who has what disease.) | | |

|Addiction: (drugs, alcohol) | |Psychiatric disorders | | | |

|Heart disease | |Hypertension | | | |

|Stroke | |Diabetes | | | |

|Cancer | |Chronic lung disease | | | |

|Osteoporosis | |Arthritis | | | |

|Kidney disease | |Tuberculosis | | | |

|Other | | | |

| | | | |

| | | |

|Social History: | | |

|Tobacco: (Pack/ year history) | | | |

|Alcohol: (type, amount, frequency) | | | |

|Illicit drugs: (type, amount, frequency) | | | |

|Marital status / family structure / role in the family | | | |

|Sexual practices | | | |

|Living arrangements | | | |

|Economic status / sources of income | | | |

|Occupational history and military service | | | |

| | | | |

|Education | | | |

|Mode of transportation | | | |

|Travel history | | | |

|Availability of help | | | |

|Social / recreational activities | | | |

|Home environment (feels safe at home?) | | | |

|Work environment | | | |

|Spiritual activities | | |Nursing diagnoses with |

| | | |priority designation. |

| | | |H – High |

| | | |M – Moderate |

| | | |L - Low |

|Ethnic background | | | |

|Stress (perceived) | | | |

|Content of an average day: “How does your day go? | | | |

| | | |

|REVIEW OF SYSTEMS (all subjective data) | | |

| All positive responses require further explanation under “comments” | | |

|General: | | |

| |Sleep/rest | | | |

| |Activity/exercise | | | |

| |Ability to perform self care activities | | | |

| |Nutrition | | | |

| |Present and usual weight | | | |

| | | |

|Neurological: | | |

| |Headache | | | |

| |Change in balance, coordination, loss of movement, tremors, and involuntary | | |

| |movement | | | |

| |Change in sensory perception / feeling in extremity (numbness, tingling) | | |

| | | | |

| |Change in speech | |Cha| |

| | | |nge| |

| | | |in | |

| | | |sme| |

| | | |ll | |

| |Comments | | | |

| | | |

|Psychological/Emotional: | | |

| |Irritability | |Ner| |

| | | |vou| |

| | | |sne| |

| | | |ss | |

| |History of psychiatric care | | | |

| |Usual coping mechanisms | | | |

| |Defense mechanisms (Varcarolis p. 215- 217) | | | |

| |Comments | | | |

|Integumentary system: | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| |Rashes | |Itc| |

| | | |hin| |

| | | |g | |

| |Odors, excessive sweating | | | |

| |Hair distribution (any changes) | | | |

| |Changes in nails | | | |

| |Amount of time | |Use| |

| |in sun | |of | |

| | | |sun| |

| | | |scr| |

| | | |een| |

| | | |

|Head, Ears, Eyes, Nose, Throat (HEENT): | | |

|Head | | |

| |Dizziness | |Hea| |

| | | |dac| |

| | | |he | |

| |Comments | | | |

| | | |

|Eyes | | |

| |Change in | |Dip| |

| |vision | |lop| |

| | | |ia | |

| |Floaters | |Hal| |

| | | |os | |

| |Comments | | | |

| | | |

|Ears | | |

| |Hearing | |Hea| |

| | | |rin| |

| | | |g | |

| | | |aid| |

| |Tinnitus | |Pai| |

| | | |n | |

| |How do you clean your ears? | | | |

| |Comments | | | |

|Nose | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| |Drainage | |Ble| |

| | | |edi| |

| | | |ng | |

| |Pain | |Pri| |

| | | |or | |

| | | |inj| |

| | | |uri| |

| | | |es | |

| | | |

|Throat | | |

| |Dysphagia | |Dif| |

| | | |fic| |

| | | |ult| |

| | | |y | |

| | | |eat| |

| | | |ing| |

| | | |, | |

| | | |che| |

| | | |win| |

| | | |g | |

| |Comments | | | |

| | | |

|Neck | | |

| |Swollen | |Goi| |

| |glands | |ter| |

| |Comments | | | |

| | | |

|Respiratory system | | |

| |Cough | |Pro| |

| | | |duc| |

| | | |tiv| |

| | | |e | |

| |SOB | |DOE| |

| |Do people tell you that you snore? | | | |

| |Comments | | | |

| | | |

|Cardiovascular system | | |

| |Chest pain | |Pal| |

| | | |pit| |

| | | |ati| |

| | | |ons| |

|Breasts | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| |Pain | |Ten| |

| | | |der| |

| | | |nes| |

| | | |s | |

| |Lumps, change in | |Dim| |

| |size | |pli| |

| | | |ng | |

| | | |

|Gastrointestinal system | | |

| |Usual elimination pattern | | | |

| |Black tarry | |Ind| |

| |stools | |ige| |

| | | |sti| |

| | | |on,| |

| | | |dys| |

| | | |pep| |

| | | |sia| |

| | | |, | |

| | | |ref| |

| | | |lux| |

| |Comments | | | |

| | | |

|Genitourinary system | | |

| |Usual elimination pattern | | | |

| |Inc| |

| |ont| |

| |ine| |

| |nce| |

| |For females: | | |

| |Las| |

| |t | |

| |men| |

| |str| |

| |ual| |

| |per| |

| |iod| |

| |For males: | | |

| |Testicular pain | |Mas| |

| | | |ses| |

| |Comments | | | |

|Musculoskeletal system | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| |Muscle weakness | |Pain | |Ten| |

| | | | | |der| |

| | | | | |nes| |

| | | | | |s | |

| |Joint pain, swelling | |Backache | | | |

| |Deformities | |History of fractures | | | |

| |Any problems with hands, feet? | | | |

| |Use of ambulatory aids | | | |

| |Comments | | | |

| | | |

|PHYSICAL EXAMINATION (ALL OBJECTIVE DATA) | | |

|Vital signs: |T: P: R: Pain Level: | | |

| |BP: Lying | |Which arm? | | | |

| |Sitting: | | | |

| |Standing: | | | |

|Height: | |Weight: | |Ideal body weight: (range) | | | |

|IBW Reference: | | | |

|General Appearance of the Patient : (General description, appearance, gait, speech, facial expression/affect, | | |

|affect, LOC, sex, race, orientation, thought processes, body language). | | |

| | | |

| | | |

| | | |

|Grooming: | | | |

|Posture: | | | |

|Expression: | | | |

| | | |

|Integumentary | | |

|Skin, Hair, and Nails (using inspection, palpation) | | |

|Skin | | |

|Color: | |Lesions: | | | |

|Moisture: | |Temperature: | | | |

|Texture: | |Turgor: | | | |

|Edema: | Braden Scale Score: | | |

|Bleeding, ecchymosis, vascularity: | | | |

|Hair | | |

|Color: | |Distribution: | | | |

|Texture: | |Scalp lesions: | | | |

|Nails | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

|Color: | |Shape/ configuration: | | | |

|Clubbing: | |Texture: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment | | | |

|book (referenced with pg. #): | | | |

| | | |

|Head, Eyes, Ears, Nose, Throat (HEENT) (using inspection, palpation) | | |

|Head | | |

|Shape: | |Symmetry: | | | |

|Contour: | |Tenderness: | | | |

|Masses: | |Depressions: | | | |

|Comments: | | | |

|Face | | |

|Shape: | |Symmetry: | | | |

|Comments: | | | |

|Eyes | | |

|Visual acuity: (near, distance) | | | |

|External eyes: Eyelids: | | | |

|Lacrimal apparatus: | |Drainage: | | | |

|Extra ocular muscle (EOM) function: 6 cardinal fields of gaze: | | | |

| | | |

|Conjunctiva: | |Sclera: | | | |

|Cornea: | |Iris: | | | |

|Pupil size: Rt: | |Lt: | | | |

|Pupillary light reflex (direct, consensual, accommodation): | | | |

|Comments: | | | |

|Ears | | |

|Auditory screening: (voice-whisper test) | | | |

|External ear: | | |

|Color: | |Size: | |Placement: | | | |

|Deformities: | |Nodules: | | | |

|Inflammation: | |Lesions: | | | |

|Comments: | | | |

|Nose | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

|Shape: | |Patency of nares: Rt: | |Lt: | | | |

|Internal inspection: | | | |

|Sinuses: Frontal: | |Maxillary: | | | |

|Comments: | | | |

|Mouth | | |

|Breath: | |Lips: | | | |

|Tongue: | |Buccal mucosa: | | | |

|Gums: | |Teeth: | | | |

|Palate: | | | |

|Comments: | | | |

|Throat | | |

|Posterior pharynx: | | | |

|Tonsils: | | | |

|Gag reflex: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment | | | |

|book (referenced with pg. #): | | | |

| | | |

|Neck (using inspection, palpation, and auscultation) | | |

|ROM: | | | |

|Enlarged lymph nodes: (preauricular, postauricular, occipital, submental, submandibular, | | |

|anterior cervical chain, posterior cervical chain tonsillar) | | | |

| | | |

|Trachea: | |Carotid bruits: | | | |

|Thyroid: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg. #): | | |

|________________________________________________ | | |

| | | |

|Breasts, Regional Nodes (inspection, palpation) | | |

|Color: | |Size: | |Symmetry: | | | |

|Contour: | |Vascularity: | | | |

|Discharge: | | | |

|Lymph nodes: Supraclavicular: | |Infraclavicular: | | | |

|Axillary: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment | | | |

|book (referenced with pg. #): | | | |

|Respiratory System | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

|Thorax and Lungs (inspection, palpation, auscultation) | | |

|Thorax | | |

| |Shape: | |Symmetry of chest wall: | | | |

| |Presence of superficial veins: | | | |

| |Muscles of respiration: | | | |

| |Tenderness to palpation: | | | |

| |Thoracic expansion: | | | |

| |Costal angle: | |Angle of ribs: | | | |

| |Tactile Fremitus: | | | |

|Respirations | | |

| |Rate: | |Patt| |

| | | |ern:| |

| |Patient position: | | | |

| |Mode of breathing: | | | |

| |Cough: (productive or nonproductive) | | | |

| |Sputum: Color: | |Odor: |

|Lungs | | |

| |Breath sounds: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg. #): | | |

| | | | |

| | | |

|Cardiovascular System | | |

|Heart and Peripheral Vasculature (inspection, palpation, auscultation) | | |

|Precordium (Indicate the location where heart sounds are auscultated.) | | |

| |Aortic: | | | |

| |Pulmonic: | | | |

| |Tricuspid: | | | |

| |Mitral: | | | |

| |PMI: | | | |

| |Lifts: | |Thrills: | | | |

|Jugular vein distention: | | | |

|Heart sounds | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| |Rate: | |Rhythm: | | | |

| |S1 | |S2 | |

| |Rubs: | |Prosthetic Heart Valves: | | | |

|Peripheral Vasculature | | |

|Capillary refill time (CRT): | | | |

|Arterial Pulses: (grade on 0-4 scale) | | |

| |Carotid: |Rt. | |Lef| |

| | | | |t: | |

|Hair distribution: | | | |

|Assistive devices: | | |

| |Pacemaker: (temporary or permanent): | | | |

| |Hemodynamic monitoring: | |Pulse Oximetry : | | | |

| |Telemetry monitoring: | | | |

| |Antiembolic Stocking: | |Pneumatic Compression Devices: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg. #): | | |

| | | | |

|Gastrointestinal System | | |

|Liver, Spleen and Stomach | | |

|Abdomen (inspection, auscultation, palpation) | | |

|Contour: | |Symmetry: | | | |

|Pigmentation & Color: | | | |

|Scars: | |Umbilicus: | | | |

|Striae: | |Respiratory movement: | | | |

|Masses, nodules: | | | |

|Visible peristalsis: | |Fluid wave: | | | |

|Pulsations: | | | |

|Drains, tube: | | | |

|Intestinal diversions: | |Urinary diversions: | | | |

|Bowel sounds: | | |Nursing diagnoses with |

| | | |priority designation. |

| | | |H – High |

| | | |M – Moderate |

| | | |L - Low |

|Vascular sounds: | |(aortic bruit) Friction rub: | | | |

|Continence: | | | |

|Tenderness, pain: | |Rebound tenderness: | | | |

|Comments: | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg. #): | | |

| | | | |

|Rectal | | |

|Fissures: | |Hemorrhoids: | | | |

|Other: | | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg.#) | | |

|_________________________________________________________ | | |

| | | |

|Genitourinary (Inspection) | | |

|Elimination: Color: | |Cla| |

| | |rit| |

| | |y: | |

|Catheter: | |Suprapubic: |

|Female (note: may be deferred): | | |

|Pubic hair distribution: | |Skin color / condition: | | | |

|External structures: mons pubis: | |Vulva: | | | |

|Perineum: | | | |

|Vaginal Introitus: | |Clitoris: | | | |

|Urethral meatus: | |CVA tenderness: | | | |

|Discharge: | |Col| |

| | |or:| |

|Male: (note, may be deferred): | | |

|Pubic hair distribution: | | | |

|Penis: | |Scrotum: | | | |

|Perineum: | |Urethral meatus: | | | |

|Discharge: | |Col| |

| | |or:| |

|Other: | | | |

|Describe developmental changes for this age patient according to assessment book (referenced with pg. #): | | |

| | | |

|Musculoskeletal (inspection, palpation) | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

| | | |

|Overall appearance: | | | |

|Posture: | | | |

|Gait: | |Mobility: | | | |

|Muscle strength: |Upper extremities (arms, forearms, and hands) | | | |

| |Lower extremities (legs, feet) | | | |

|Range of Motion: |Upper extremities: | |Low| |

| | | |er | |

| | | |ext| |

| | | |rem| |

| | | |iti| |

| | | |es:| |

| |Legs: | | | |

| |Feet: | | | |

|Assistive| |Cane: | |Wal| |

|devices: | | | |ker| |

|Crutches:| | | |: | |

|Skeletal Traction: | |External Fixations: | | | |

|Comments: | | | |

|Describe the normal developmental changes for this age patient according to assessment book (referenced with | | |

|pg. #): _________________________________________________________ | | |

| | | |

|Neurological/mental status | | |

|Level of consciousness: | | | |

|Glascow Coma Scale Score: | | | |

|Orientation: | | | |

| | | |

|Sensory Assessment | | |

| |Touch: | |Sup| |

| | | |erf| |

| | | |ici| |

| | | |al | |

| | | |pai| |

| | | |n: | |

| |Motion & Position Sense: | | | |

| |Involuntary movements, tremors: | | | |

|Cranial Nerves (Must include “as evidenced by” or AEB) | | |

|CN I: Olfactory: | | | |

|CN II: Optic: Assessed with vision screening: | | | |

|CN III: Oculomotor: Assessed with Extra Ocular Muscle (EOM) and pupillary response | | |

|CN IV: Trochlear: Assessed with Extra Ocular Muscle (EOM) | | | |

|CN V: Trigeminal: | | | |

|CN VI: Abducens: Assessed with Extra Ocular Muscle (EOM’s) | | | |

|CN VII: Facial: | | | |

|CN VIII: Acoustic: Assessed with hearing screening | | | |

|CN IX: Glossopharyngeal: | | | |

|CN X: Vagus: Assessed with gag and swallowing | | | |

|CN XI: Spinal Accessory: | | |Nursing diagnoses with |

| | | |priority designation |

| | | |H – High |

| | | |M – Moderate |

| | | |L - Low |

|CN XII: Hypoglossal: | | | |

|Development | | |

|Developmental Stage (Erickson): | | | |

| | | |

|Is the Patient Meeting Task? | | | |

|Describe How the Patient is Meeting/Not Meeting the Task. Include specific examples. | | |

| | | |

|PHYSICIAN’S ORDERS | | |

|Diet: | | | |

|Activity: | | | |

|Treatments: | | | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Current medications (including IV and supplemental feeding). List medication, dosage, route, frequency | | |

|Medication/IV Fluids |Reason |Dosage |Route |Frequency | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

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| | | | | | | |

|DIAGNOSTIC TESTS | |Nursing diagnoses with |

| | |priority designation. |

| | |H – High |

| | |M – Moderate |

| | |L - Low |

|Laboratory Data: Include all pertinent lab data | | |

| | | |

|Test |Reason |Admission Values |Current Values |Normal Values | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | |

|Radiology / Nuclear Medicine Tests | | |

| | | |

|Type of Test |Findings | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Other pertinent diagnostic tests | | | |

| | | |

| | | |

| | | |

|Identify teaching and referral needs: | | | |

| | | |

| | | |

| | | |

| | | |

|Scientific Rationale for highest priority problem (#1 nursing diagnosis) . | | |

| | | | |

| | | |

| | | |

| | | |

| | | |

|Short Term Goal (STG) for #1 nursing diagnosis: | | | |

| | | |

|Long Term Goal (LTG) for #1 nursing diagnosis: | | | |

| | | |

N:ADN Syllabus\Core\Patient Assessment Level I & II & Transition Revised 04/13

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