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DATE: DATE:
PRE ASSESSMENT PATHOPHYSIOLOGIC BASIS POST ASSESSMENT PATHOPHYSIOLOGIC BASIS
TYPE OF FAMILY:
SIGNIFICANT OTHERS:
COPING MECHANISM:
P
S RELIGION:
Y
C
H
O DIALECT:
S
O PRIMARY SOURCE OF HEALTH:
C
I FINANCIAL RESOURCES:
A
L
GENERAL APPEARANCE:
GCS SCORE:
Motor response 6 Obeys commands fully
5 Localizes to noxious
stimuli
4 Withdraws from noxious
Verbal response stimuli
3 Abnormal flexion, i.e.
decorticate posturing
2 Extensor response, i.e.
Eye opening decerebrate posturing
1 No response
AFFECT:
NON-VERBAL BEHAVIORS:
Shaking of head She shakes her head Smiling She smiles and nods whenever she agrees to what
whenever she agrees Nodding the student nurse say.
Facial Grimace with poor to what the student
eye contact nurse says.
Due to backpain
STOOL: Pattern:
E Pattern: Consistency:
L Consistency: Color:
I Color: Frequency:
M
Frequency: Quantity:
I
N Quantity: Contour:
A Contour: Abdominal Girt:
T Abdominal Girt:
I
O URINE: Frequency:
N Frequency: Color:
Color: Specific Gravity:
Specific Gravity: Clarity:
Clarity: Clarity:
Quantity: Quantity:
Contraption: Contraption:
A Position: Position:
C Characteristics: Characteristics:
T
I
BODY FRAME:
V
I
T POSTURE:
Y
GAIT:
COORDINATION:
BALANCE:
Unsteady
MUSCLE (skill)
Strength: -
Right Arm 5Active motions against full
Left Arm resistance.
Right Leg 4 Active motion against
Left Leg some resistance.
3 Active motion against
Mass/Tone: gravity.
2 Passive ROM (gravity
Right Leg removed and assisted by
Left Leg - examiner)
1 Slight flicker of contraction.
0 No muscular contraction.
Cervical spine
Flexion of the cervical spine
is 45 degrees. The
extension of cervical spine
is 45 degrees.
Elbows
Increased ROM against
resistance on both elbow
Wrists
The client is able to bend
S the both wrist down and
A
back
F
E Hands and fingers
T The client was able to move
Y the both hand
Hips
A The client was able to move
N the both for hip assessment
D
Knees
E The client can extend or flex
N both knees
V Ankles and feet
I
R
Both ankles can abduct,
O adduct and dorsiflex.
N She can turn foot outward
M and inward
E
N Use of Device:
T None
ALLERGIES:
Medication
Food
Environment
EYES:
Vision
Accommodation PERRLA
Conjunctivae
Sclera Clear
Cornea White
Glasses No eye glasses
HEARING/HEARING AID:
No hearing aid Able to answer whispered
No hearing Impairment questions.
The client doesnt use
hearing aid.
MUCOUS MEMBRANE:
Lips
Oral Activity
AIRWAY CLEARANCE:
Nose: No secretions; Clear The client is able to
Mouth: No lesions and sniff through each
secretions noted; Clear nostril without difficulty.
No blockages or
O obstructions noted.
X RESPIRATION:
Y Rhythm: -Even or Uneven Rhythm:
G Effort:
E Effort: -Ease, quiet or with great effort
N Depth:
A Expansion:
T Depth: -Deep or shallow
I Cough:
O Expansion: -Symmetric or asymmetric
N
Auscultation:
Cough: -Productive or Non-productive
or absent
Oxygen therapy:
Lung sounds:
No crackles and Rales upon
auscultation
Normal breath sounds.
N
U SKIN INTEGRITY: (insert picture)
T Color
R Texture
I
T Edema
I Temperature
O
N Turgor
NAILS:
Color:
Capillary Refill:
PERIPHERAL PULSE:
Location: Pulse scale: Location:
Pulse scale: 0-Absent Pulse scale:
Color: 1+ -Diminished, barely Color:
Skin: palpable, easy to obliterate Skin:
Edema: 2+ -Easily palpable Edema:
3+ -Full pulse, increased
4+ -Strong, bounding, cannot
be obliterate
IVF:
Site: Site:
Solution: Solution:
Regulation: Regulation:
Incorporation: Incorporation:
HOSPITAL DIET/RESTRICTIONS:
Therapeutic Diet: (NPO) Therapeutic Diet:
Fluid Intake: Fluid Intake:
Gag Reflex: Intact Gag Reflex: >underweight, over, or normal
Height: Height: After pregnancy; what is her bmi?
Weight: Weight:
BMI: Underweight = <18.5 BMI:
Normal weight = 18.524.9
Overweight = 2529.9
Obesity = BMI of 30 or
greater