Patient Name:__Sherman Yoder _Rm#___16

DOB_02/02/1931 Age__80_ ___

MRN _000-555-555

Inpatient Hospital Day 3- ICU-Nursing Assessment
GENERAL APPEARANCE:
[x ] male [ ] female DOB:2/2/1931_________
Age__80_______Ethnicity__White_______
Occupation __retired_________ Religion_______________
[ ] awake [ ] cheerful [ ] crying [ ] sleeping [ ] lethargic
[ ] calm [X] agitated [ ] anxious [ ] combatative [X ]fearful
RESPIRATORY[ ] see nursing notes
RESPIRATIONS: Rate__32__ O
2
____91___ SPO
2
_10% nonrebreather
[ ]reg [ ] even [ ] irreg [X ] labored
[ ] uses accessory muscles [ ] cough
BREATH SOUNDS:
RIGHT: [ ] clear [ ] crackles [ ] wheezes
[X ] decreased [ ] absent
Left: [ ] clear [ ] crackles [ ] wheezes
[ X] decreased [ ] absent
THORAX: [X ] even expansion [ ] uneven expansion
SMOKING: cigarettes pk/day ____________ [ ] cigars
[ ] marijuana [ ] cocaine
Chewing Tobacco for 30 yrs..quit 20 years ago
SKIN [X] (see wound care sheet)[ ] see nursing notes
Braden scale score: 12 [X] risk skin breakdown
COLOR: [ ]acyanotic [ ] pale [ ] ruddy [ ] jaundiced [ ] cyanotic
TEMP: [ ] warm/dry [ ] hot [ ] cool [ ]cold/clammy [X ]diaphoretic
TURGOR: [ ]<3 sec [X ] > 3 sec
HAIR: [ ] shiny [X ]dry/flaking [ ]balding [ ] lesions [ ] lice
NEUROLOGICAL[ ] see nursing notes
ORIENTATION: [X ] person [ ] place [ ] time
[ ] Disoriented: [X ] confused [ ] impaired memory
RESPONDS TO: [X ] name [ ] stimuli [ ] non-responsive
SPEECH: [X ] clear [ ] garbled [ ] slurred [ ] aphasic
[ ] 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 [ ] see nursing notes
APPEARANCE: [ ] flat [ X] round [ ] obese [X ] soft [ ]gravid
BOWEL SOUNDS:
[ ] active [X ] hypoactive [ ] hyperactive [ ] absent
PALPATION:
[X ] non-tender [ ] tender (location)__________
[ ] mass (location) _____________
LAST BM:____3 days ago____[ ] incontinent [ ] stoma- _______
[ ] constipation [ ] diarrhea [ ] mucous [ ] blood
Diet:___NPO___________ [X ] impaired swallowing [ ] choking
[ ] NG tube Color drainage______________[ ] Feeding tube
[ ] tube feeding Type: ______________ Rate:_________
MUSCULOSKELETAL[ ] see nursing notes
GAIT: [ ] steady [ ] unsteady [X ] non-ambulatory
ACTIVITY: [ ] up ad lib [ ] walker [ ] cane [ ] crutches [ ] wheelchair
Assist: [ ] x1 [ ] x2 [ ] lift [X ] bed bound
HAND GRIPS: Amputation [ ] right [ ] left Location____________
RIGHT: [ ] strong [X ] weak [ ] flaccid [ ] contractures
LEFT: [ ] strong [X ] 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 occasional incontinence X
APPEARANCE OF URINE:
[ ] clear [ ] light yellow [X ] 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: [ ] urinary retention [ ] 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: [ ]reg [ ] irreg [ ] strong [X ] faint [ ] nonpalpable
PEDALIS: [ ]reg [ ] irreg [ ] strong [X ] faint [ ] nonpalpable
EXTREMITY COLOR & TEMP:
[ ] warm [X ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]discolor
EDEMA: [ ] none [x ] generalized (anasarca)
Site #1___2+_____________
[ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
Site #2 ________________
[ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting
CAPILLARY REFILL: Fingers [ ] brisk [ X] slow
Toes: [ ] brisk [X ] slow
Hx: [ ] Pacemaker [ ] HTN [ ] CAD [ ] CHF [ ] PVD Other:_______
PAIN ASSESSMENT: [ ] see nursing notes [ ] see MAR
PRECIPITATING:_____________________________________
QUALITY:___Throbbing__________________________________
REGION:__Big toe of foot_________________________________
SEVERITY 0-10/10: Now __7___ at worst __9____at best __4_____

SAFETY:[ ] see nursing notes [ ] Fall risk
PRECAUTIONS: [X ] side rails x__2_____ [x ] bed down [x ] call
light
[x ] nightlight [ ] restraints [ ] wrist [ ] vest

DISCHARGE/TEACHING: [ ] see nursing notes
NEEDS:__________________________________________________
______________________________________________
TYPE OF LEARNER: [ ] visual [ ] auditory [x ] kinesthetic
Educational level ___grade 3_______Family present: [ Y] [N]
Patient Name:__Sherman Yoder _Rm#___16
DOB_02/02/1931 Age__80_ ___
MRN _000-555-555



FLUID BALANCE [ ] see nursing notes
INTAKE: [ ] PO [ ] IV: Solution: _NS________Rate___150_ ml/hr
SITE LOCATION: _20 LAC 20 RFA________ [x ] clean [x ] patent
[ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain
[ ] tubing change [ ] dressing change
MUCOUS MEMBRANES: [ ] moist [ ]pink [X ]dry [ ]sticky [ ] coated
Oral Mucosa-bumpy and reddened with patches.
Todays wt:__109 kg/240 lbs____________ Yesterdays ___________
NURSE SIGNATURE: Jenolyn Boyd RN
Time completed:
REASSESSMENT:
TIME ________ [ ] no change [ ] see nurses notes [ ] initials___
TIME ________ [ ] no change [ ] see nurses notes[ ] initials___
TIME ________ [ ] no change [ ] see nurses notes[ ] initials___