I.

NURSING ASSESSMENT

A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.
Objective
Vital Signs: T ____ P- 86 bpm R_______BP 160/95
Body Types:
Ectomorph Mesomorph
Obese
Thin

Endomorph

BMI: 23.2

Remarks: BMI = 23.2 is within normal range; liver and spleen are impalpable;
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective
Breath Sounds: Diminished/Absent Stridor
Rales/Crackles Rhonchi/Wheezing
Normal (Vesicular, Bronchovesicular, Bronchial)
None (atelectasis)
Resonance: Hyper Hypo
Respiration/Oxygenation:
Normal(Relax, Effortless and Quiet)
Labored/Use accessory Muscle] Dyspnea
Tachypnea Bradypnea
Cyanosis
Pallor
Cheyne-stoke Biots
Hyperventilation Hypoventilation
Nasal Flaring
Pursed lip Barrel Chest
Pleuritic Pain
O2 Inhalation _____liters/min
Rate: ________________________
Cough:

none

Remarks: not dyspneic; clear lungs

Nursing Diagnosis:

__________________________________________________________________________________________
__________________________________________________________________________________________

C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective
Temperature: _______________ Celsius
Blood Pressure: Right- 160/95 Left- 160/95
Pulses:
Radial Pulse:

Regular Rate: 86bpm

Heart Sounds: No heart murmurs

Heart Rhythm: Tachycardia Bradycardia
Arrhythmia/ Dysrhythmia
Jugular Veins Distention:
Positive Negative
Nail bed Color : Pink

Blue

Pale

Capillary Refill: ________ (Normal less than 2 sec)

Edema: Pitting Non Pitting
Location: _____________________________
Varicosities: Yes
No
Location: __________________________________
Calf Tenderness (Homans Sign):
Right
Positive Negative

Left

Positive Negative

Remarks: patient is not pale; no heart murmurs; jugular vein not elevated; BP= 160/95 equal in both
arms; PR = 86bpm reagular with good volume; no ankle edema

Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective
Skin: linea nigra and striae gravidarum present

Remarks: not icteric, linea nigra and striae gravidarum present,

Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

E. ELIMINATION
Objective

Subjective

Tubes/Drainage/Stoma:
Colostomy Ileostomy
NGT
Catheter
Suprapubic Catheter
Abdomen:
Soft
Firm
Distended Non-distended
Bowel Sounds: (5 20 sounds/min)
Normoactive
Hypoactive
Hyperactive(Borborygmi) Absent
Measurement:
Intake ____________ Output:_______________
Edema:
Yes
No
Location: __________________________________

Present Urine Color: ________________________

Previous/Recent Surgery/Illness:
_____________________________________________
History of pain and discomfort: _________________
_____________________________________________
Personal Elimination Habits:____________________
_____________________________________________
Elimination Problem:
Loose bowel movement _________
Constipation Impaction Fecal Incontinence
Neurologic Impairment Dysuria Urgency
Polyuria Oliguria
Nocturia Dribbling
Incontinence Hematuria Retention
Discharge
Urinary Elimination changes _________________
Residual urine (> 100ml)
Comment: ___________________________________
_____________________________________________

Note: Assess urine frequency, color, odor control,

comfort/gyn-bleeding, discharge.

Medication taken:
Analgesic Narcotic
Antibiotics Anticholinergic NSAID
Comment: __________________________________
H2 antagonist
___________________________________________ Aspirin
___________________________________________
___________________________________________ Fluid intake per day: __________ liters/day
___________________________________________
___________________________________________ Physical Activity: _____________________________
___________________________________________ Comment: ___________________________________
_____________________________________________
Excessive Perspiration and Odor Problem:
Yes No
Consistency:
Stools: ______________________________________
Remarks: urinary dipstick is 2+ for proteinuria.
Nursing Diagnosis: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Obstetric Data:
Period of amenorrhea: 32 weeks
Fundal height- 31 cm
Cephalic, not engaged
FHT noted
dipstick is 2+ for proteinuria.