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. | | |
| | | |
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| | | |
|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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|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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