Patient Name:__Sherman Yoder _

DOB_02/02/1931 Age__80_ __
MRN _000-555-555
Nursing Assessment-Day 4-Medical/Surgical Unit


GENERAL APPEARANCE:
[X ] male [ ] female DOB:_2/2/1931 Age:80__
Ethnicity: Caucasian______
Occupation: retired__________ Religion: none___________
[ X] awake [ X] cheerful [ ] crying [ ] sleeping [ ] lethargic
[ ] calm [ ] agitated [ ] anxious [ ] combatative [ ]fearful
RESPIRATORY[ ] see nursing notes
RESPIRATIONS: Rate______ O
2
_________ SPO
2
______%
[ X]reg [X ] even [ ] irreg [ ] labored
[ ] uses accessory muscles [ ] cough
BREATH SOUNDS:
RIGHT: [ X] clear [ ] crackles [ ] wheezes
[ ] decreased [ ] absent
Left: [ x] clear [ ] crackles [ ] wheezes
[ ] decreased [ ] absent
THORAX: [ X] even expansion [ ] uneven expansion
SMOKING: cigarettes pk/day ____________ [ ] cigars
[ ] marijuana [ ] cocaine
History of chewing tobacco
SKIN [X ] (see wound care sheet)[ ] see nursing notes
Braden scale score: 12 [ X] risk skin breakdown
COLOR: [X ]acyanotic [ ] pale [ ] ruddy [ ] jaundiced [ ] cyanotic
TEMP: [ X] warm/dry [ ] hot [ ] cool [ ]cold/clammy [ ]diaphoretic
TURGOR: [X ]<3 sec [ ] > 3 sec
HAIR: [ ] shiny [ ]dry/faking [X ]balding [ ] lesions [ ] lice
NEUROLOGICAL[ ] see nursing notes
ORIENTATION: [X ] person [X ] place [ ] time
[ ] Disoriented: [ ] confused [ X] impaired memory
RESPONDS TO: [ X] name [ ] stimuli [ ] non-responsive
SPEECH: [ ] clear [ ] garbled [ ] slurred [ ] aphasic
[X ] inappropriate [ ] cannot follow conversation
FACE: [X ] symmetrical [ ] drooping [ ] drooling
EYES: [X ] PERRLA [ ] unequal [ ] drooping lid
SIGHT: [ ] no correction [ X] glasses [ ] contacts [ ] blind
HEARING: [ ] WNL [X ] HOH [ ] hearing aid
Hx: [ ] seizures [ ] CVA [ ] brain injury [ ] spinal injury [ ] other
GASTROINTESTINAL/NUTRITION [ X] see nursing notes
APPEARANCE: [ ] flat [ ] round [ ] obese [X ] soft [ ]gravid
BOWEL SOUNDS:
[ X] active [ ] hypoactive [ ] hyperactive [ ] absent
PALPATION:
[ X] non-tender [ ] tender (location)__________
[ ] mass (location) _____________
LAST BM: yesterday_____[ ] incontinent [ ] stoma- _______
[ ] constipation [ ] diarrhea [ ] mucous [ ] blood
Diet:______________ [X ] impaired swallowing [ ] choking
[ ] NG tube Color drainage______________[ ] Feeding tube
[ ] tube feeding Type: ______________ Rate:_________
MUSCULOSKELETAL[ ] see nursing notes
GAIT: [ ] steady [ ] unsteady [ ] non-ambulatory
ACTIVITY: [ ] up ad lib [ ] walker [ ] cane [ ] crutches [ ] wheelchair
Assist: [ ] x1 [X ] x2 [ ] lift [ ] bed bound
HAND GRIPS: Amputation [ ] right [ ] left Location____________
RIGHT: [X ] strong [ ] weak [ ] flaccid [ ] contractures
LEFT: [X ] strong [ ] weak [ ] flaccid[ ] contractures
ROM:
ARMS: [ ] full [X ] weak [ ] flaccid [ ] contractures
LEGS: [ ] full [X ] weak [ ] flaccid [ ]contractures [ ]TED hose
AMPUTATION: [ ] right [ ] left [ ] BKA [ ] AKA [ ] other
SPINE: [ ]kyphosis [ ] scoliosis [ ] osteoporosis
OTHER: [ ] Cast location:___________ [ ] Traction_____________
GENITOURINARY[ ] see nursing notes
[] Voids [X ] catheter [ ] stoma
APPEARANCE OF URINE:
[ X] clear [X ] light yellow [ ] amber [ ] brown
[ ]cloudy [ ] sediment [ ] red/wine [ ] clots
BLADDER: [X ] soft [ ] firm/distended [ ] incontinent

FEMALES: LMP: _________ [ ] WNL [ ] dysmenorrheal
Birth control:[ ] yes [ ] no [ ] BSE monthly
[ ] menopause [ ] taking estrogen

SEXUALITY: [ ] sexually active [ ] safe sex
MED HX: [X ] urinary retention [ X] BPH [ ] Frequent UTI
CARDIOVASCULAR[ ] see nursing notes
HEART SOUNDS: [ X] normal S
1
-S
2
[ ] Abnormal S
3
-S
4
[ ] murmur
PULSE: APICAL: [X ]reg [ ] irreg [ ] strong [ ] faint
RADIAL: [ X]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable
PEDALIS: [X ]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable
EXTREMITY COLOR & TEMP:
[ X] warm [ ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]discolor
EDEMA: [ ] none [ ] generalized (anasarca)
Site #1___Pedal____________
[ ] pitting [ X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
Site #2 ________________
[ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
CAPILLARY REFILL: Fingers [X ] brisk [ ] slow
Toes: [X ] brisk [ ] slow
Hx: [ ] Pacemaker [ ] HTN [ ] CAD [ ] CHF [ ] PVD Other:_______
PAIN ASSESSMENT: [ ] see nursing notes [ ] see MAR
PRECIPITATING:_____________________________________
QUALITY:___________________________________________
REGION:Right great toe _____________________________________
SEVERITY 0-10/10: Now __4___ at worst ___5___at best ____3___
TIMING:
SAFETY:[ ] see nursing notes [ ] Fall risk
PRECAUTIONS: [ ] side rails x_______ [ ] bed down [ ] call light
[ ] nightlight [ ] restraints [ ] wrist [ ] vest

DISCHARGE/TEACHING: [ ] see nursing notes
NEEDS:__________________________________________________
______________________________________________
TYPE OF LEARNER: [ ] visual [ ] auditory [ ] kinesthetic
Educational level _____________Family present: [ Y] [N]
FLUID BALANCE [ ] see nursing notes
INTAKE: [ ] PO [ ] IV: Solution: Saline Lock_Rate_______ ml/hr
SITE LOCATION: _____________ [ ] clean [ ] patent
[ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain
[ ] tubing change [ ] dressing change
MUCOUS MEMBRANES: [ ] moist [ ]pink [ ]dry [ ]sticky [ ] coated
Todays wt:______________ Yesterdays wt:__________________
NURSE SIGNATURE: Doris Lansky
Time completed: 0730
REASSESSMENT:
TIME 1000____ [ ] no change [ X] see nurses notes [ ] initials___
TIME _1700____ [ ] no change [ X] see nurses notes[ ] initials___
TIME ________ [ ] no change [ ] see nurses notes[ ] initials___