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    Nursing Assessment

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    JD AIZA CASANDRA O. SANCHEZ
    This nursing assessment document contains subjective and objective data collected from a patient. In the subjective section, the patient reported no issues with hearing, vision, speech, smoking history, cough, sputum, chest pain, leg pain, numbness, diet, weight changes, swallowing, bowel habits, urinary symptoms, skin, pain, sleep, or coping. The objective assessment found the patient's respiratory rate and heart rhythm to be regular, with clear breath sounds and no edema. The patient was fully oriented with steady gait and normal range of motion. No abnormalities were observed for skin, neurologic function, or mobility. Relevant medical history, social support systems, and plans for diagnostic testing were also

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    Nursing Assessment

    Uploaded by

    JD AIZA CASANDRA O. SANCHEZ
    45 views3 pages
    This nursing assessment document contains subjective and objective data collected from a patient. In the subjective section, the patient reported no issues with hearing, vision, speech, smoking history, cough, sputum, chest pain, leg pain, numbness, diet, weight changes, swallowing, bowel habits, urinary symptoms, skin, pain, sleep, or coping. The objective assessment found the patient's respiratory rate and heart rhythm to be regular, with clear breath sounds and no edema. The patient was fully oriented with steady gait and normal range of motion. No abnormalities were observed for skin, neurologic function, or mobility. Relevant medical history, social support systems, and plans for diagnostic testing were also

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    NURSING ASSESSMENT

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    This nursing assessment document contains subjective and objective data collected from a patient. In the subjective section, the patient reported no issues with hearing, vision, speech, smoking history, cough, sputum, chest pain, leg pain, numbness, diet, weight changes, swallowing, bowel habits, urinary symptoms, skin, pain, sleep, or coping. The objective assessment found the patient's respiratory rate and heart rhythm to be regular, with clear breath sounds and no edema. The patient was fully oriented with steady gait and normal range of motion. No abnormalities were observed for skin, neurologic function, or mobility. Relevant medical history, social support systems, and plans for diagnostic testing were also

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    45 views3 pages

    Nursing Assessment

    Uploaded by

    JD AIZA CASANDRA O. SANCHEZ
    This nursing assessment document contains subjective and objective data collected from a patient. In the subjective section, the patient reported no issues with hearing, vision, speech, smoking history, cough, sputum, chest pain, leg pain, numbness, diet, weight changes, swallowing, bowel habits, urinary symptoms, skin, pain, sleep, or coping. The objective assessment found the patient's respiratory rate and heart rhythm to be regular, with clear breath sounds and no edema. The patient was fully oriented with steady gait and normal range of motion. No abnormalities were observed for skin, neurologic function, or mobility. Relevant medical history, social support systems, and plans for diagnostic testing were also

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    NURSING ASSESSMENT

    SUBJECTIVE DATA OBJECTIVE DATA


    COMMUNICATION [ ] Glasses [ ] Languages
    Comments: [ ] Contact Lens [ ] Hearing Aide
    [ ] Hearing Loss R L
    [ ] Visual Changes Pupil Size: [ ] Speech difficulties
    [ ] Denied Reaction:

    OXYGENATION: Resp. [ ] Regular [ ] Irregular


    [ ] Dyspnea Comments: Describe: Respiratory pattern is regular and without
    [ ] Smoking History difficulty RR -
    [ ] Cough
    [ ] Sputum R: Symmetric to left: with full
    [ ] Denied L:

    CIRCULATION: Heart Rhythm [ ] Regular [ ] Irregular


    [ ] Chest pain Comments: Ankle Edema:
    [ ] Leg pain Carotid Radial Dorsalis Pedalis Femoral
    [ ] Numbness of R:
    Extremities L:
    [ ] Denied Comments:

    *If applicable:

    NUTRITION: [ ] Dentures [ ] None


    Diet Comments:
    []N []V Full Partial With Patient
    [ ] Recent change in Upper [ ] [] []
    weight and appetite
    [ ] Difficulty in Lower [ ] [] []
    swallowing
    [ ] Denied

    ELIMINATION: Comments: Bowel Sounds:


    Usual bowel pattern [ ] Urinary frequency
    Abdominal Distention
    [ ] Constipation [ ] Urgency Present [ ]Yes [ ]No
    [ ] Dysuriaa Urine* (color,
    [ ] Hematuria consistency, odor)
    Date of last BM [ ] Incontinence
    [ ] Polyuria
    [ ] Foley in place *if foley bag catheter
    [ ] Diarrhea character [ ] Denied is in place

    Briefly describe the patient’s ability to follow treatments


    (diet, meds, etc.) for chronic health problems (if present).
    MGT. OF HEALTH & ILLNESS:
    [ ] Alcohol [ ] Denied
    (amount, frequency)
    [ ] SBE Last Pap Smear:
    LMP:
    SKIN INTEGRITY: [ ] dry [ ] cold [ ] pale
    [ ] Dry Comments: [ ] flushed [ ] warm
    [ ] Itching [ ] moist [ ] cyanotic
    [ ] Other *rashes, ulcers, decubitus (describe size, location,
    [ ] Denied drainage)

    ACTIVITY / SAFETY: [ ] LOC and orientation:


    [ ] Convulsion Comments:
    [ ] Dizziness Gait: [ ] walker [ ] care [ ] other
    [ ] Limited motion of joints [ ] steady [ ] unsteady
    Limitation inability to Sensory and motor losses in face of extremities
    [ ] Ambulate
    [ ] Bathe self
    [ ] Other
    [ ] Denied ROM limitations:

    COMFORT / SLEEP / AWAKE [ ] facial grimaces


    [ ] Pain (location, Comments: [ ] guarding
    frequency, remedies) [ ] other signs of pain
    [ ] Nocturia
    [ ] Sleep difficulties
    [ ] Denied [ ] side rail release form signed (60+ years)

    COPING: Observed non-verbal behavior:


    Occupation
    Members of household:

    Person ( phone number)


    Most supportive person:

    SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)


    Daily weight PT/OT
    BP Shift Irradiation
    Neuro VS Urine Test
    CVP / SG Reading 24 hour Urine collection

    Date ordered Diagnostic/Laboratory Date Done Date ordered L.V. Date


    Exams Fluids/Blood Disc.

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