Patient Name:__Sherman Yoder _Rm#___16

DOB_02/02/1931 Age__80_ __
MRN _000-555-555

Nursing Assessment-Day 1-Medical/Surgical Unit
GENERAL APPEARANCE:
[X] male [ ] female DOB:__2/2/1931_______
Age___80______Ethnicity_________
Occupation _________________ Religion_______________
[X ] awake [ X] cheerful [ ] crying [ ] sleeping [ ] lethargic
[ ] calm [ ] agitated [ ] anxious [ ] combatative [ ]fearful
RESPIRATORY[ X] see nursing notes
RESPIRATIONS: Rate__18___ O
2
_________ SPO
2
______%
[ X]reg [ ] 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
SKIN [X ] (see wound care notes)[ X] see nursing notes
Braden scale score: [ 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 [ ]balding [ ] lesions [ ] lice
NEUROLOGICAL[ X] see nursing notes
ORIENTATION: [X ] person [X ] place [ ] time [ X] situation
[ ] Disoriented: [ ] confused [ X] impaired memory
RESPONDS TO: [X ] name [ ] stimuli [ ] non-responsive
SPEECH: [ X] 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 [ X] other
GASTROINTESTINAL/NUTRITION [ ] 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:_Soft_____ [ X] impaired swallowing [ ] choking
[ ] NG tube Color drainage______________[ ] Feeding tube
[ ] tube feeding Type: ______________ Rate:_________
MUSCULOSKELETAL[ ] see nursing notes
GAIT: [ ] steady [X ] unsteady [ ] non-ambulatory
ACTIVITY: [ ] up ad lib [X ] walker [ ] cane [ ] crutches [ ] wheelchair
Assist: [ ] x1 [ ] 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[X ] see nursing notes
[ ] Voids [ ] catheter [ ] stoma
APPEARANCE OF URINE:
[ ] clear [ ] light yellow [ ] amber [ ] brown
[ ]cloudy [ ] sediment [ ] red/wine [ ] clots
BLADDER: [ ] soft [ ] firm/distended [ X] incontinent

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

SEXUALITY: [ ] sexually active [ ] safe sex
MED HX: [ ] urinary retention [X ] BPH [ ] Frequent UTI
CARDIOVASCULAR[ X] see nursing notes
HEART SOUNDS: [ X] normal S
1
-S
2
[ ] Abnormal S
3
-S
4
[ ] murmur
PULSE: APICAL: [ X]reg [ ] irreg [X ] strong [ ] faint
RADIAL: [X ]reg [ ] irreg [X ] strong [ ] faint [ ] nonpalpable
PEDALIS: [ ]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable
EXTREMITY COLOR & TEMP:
[X ] warm [ ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]discolor
EDEMA: [X ] none [ ] generalized (anasarca)
Site #1________________
[ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
Site #2 ________________
[ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
CAPILLARY REFILL: Fingers [X ] brisk [ ] slow
Toes: [ ] brisk [ ] slow
Hx: [ ] Pacemaker [ ] HTN [ ] CAD [ ] CHF [ ] PVD Other:_______
PAIN ASSESSMENT: [ ] see nursing notes [ ] see MAR
PRECIPITATING:___Moving 2__________________________
QUALITY:__Throbbing____________________________________
REGION: _Right great toe____________________________
SEVERITY 0-10/10: Now ___5_ at worst ____8_at best __3____
TIMING: Now
SAFETY:[X ] see nursing notes [X ] Fall risk
PRECAUTIONS: [ ] side rails x____2__ [X ] bed down [ X] call light
[ ] nightlight [ ] restraints [ ] wrist [ ] vest

DISCHARGE/TEACHING: [ ] see nursing notes
NEEDS:___Wound
care______________________________________________________
TYPE OF LEARNER: [ ] visual [ ] auditory [X ] kinesthetic
Educational level __high school_____Family present: [ Y] [N]
Patient Name:__Sherman Yoder _Rm#___16
DOB_02/02/1931 Age__80_ __
MRN _000-555-555

Nursing Assessment-Day 1-Medical/Surgical Unit

FLUID BALANCE [X ] see nursing notes
INTAKE: [X ] PO [ ] IV: Solution: ____________Rate_______ ml/hr
SITE LOCATION: ___Right A/C 20 gauge___ [X ] clean [X ] patent
[ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain
[ ] tubing change [ ] dressing change
MUCOUS MEMBRANES: [ ] moist [ ]pink [X ]dry [ ]sticky [ ] coated
Todays wt:________ Yesterdays wt:. new admit______________
NURSE SIGNATURE:
Time completed:
REASSESSMENT:
TIME ________ [ ] no change [ ] see nurses notes [ ] initials___
TIME ________ [ ] no change [ ] see nurses notes[ ] initials___
TIME ________ [ ] no change [ ] see nurses notes[ ] initials___