Revised 01/99; 09/99; 10/08; 01/2010

KSPN / NCKTC
CORE CURRICULUM
ACTIVITY AND EXERCISE ASSESSMENT
Client's Initials ___________

Presence of:

Rm___________ Student_____________________________

YES

NO

Describe findings

Orthopnea
Dyspnea
Cough
Chest Pain
Numbness
Tingling
Fatique
Sputum
Use of Tabacco ________ Type ____________ Duration? ___________ Frequency/amount __________
Respiratory Rate ____________ Rhythem ______________ Depth ______________________
Lung Sounds - - Normal _____________ Abnormal _____________ Describe _____________________
Temperature _____________ Oral ________________ Axillary _____________ Rectal ______________

Right

Left

B/P & Pulse Lying

B/P & Pulse Sitting
B/P & Pulse Standing

Revised 01/99; 09/99; 10/08; 01/2010

Pulse

Rate

Equal Bilateral
YES
NO

Regular
Yes NO

Strength

Strength Scale

Temporal

0 Absent

Carotid

1+ Weak

Brachial

2+ Full

Radial

3+ Bounding

Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis
Apical

Presence of Edema

Pitting Edema
Yes
NO

Nonpitting Edema
Yes
NO

Remarks

Face
Hands
Fingers
Sacrum
Knees
Ankle
Foot
Other

ASSISTANCE NEEDED TO :

YES

NO

Turn self

Revised 01/99; 09/99; 10/08; 01/2010

Sit
Stand
Transfer
Ambulate

ASSISSTIVE DEVICES
Prosthesis
Crutches
Cane
Walker

Braces
Wheelchair
Transfer Belt
Restraints
Lap buddy, bed/chair alarm, etc.
Hydraulic lift
Other

RESTRICTIVE DEVICES
Cast/Splint/Brace/Traction
Suction
Oxygen needs
Foley
Monitor

Gait ___________________________ Posture _____________________________

Describe Findings _____________________________________________________________________
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Revised 01/99; 09/99; 10/08; 01/2010

RANGE OF MOTION

FULL

LIMITED

NONE

REMARKS

Head
Shoulder
Elbow
Wrist
Fingers
Hips
Knees
Ankles
Toes

Prescribed Exercise and/or rehabilitation

____________________________________________________________________________________
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What are the activities of a routine day?
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Significant findings from physician assessment.
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Significant findings from lab/ x-ray/ procedures. Include date test completed.
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Potential / Actual nursing diagnosis derived from this health care pattern assessment:
____________________________________________________________________________________

Revised 01/99; 09/99; 10/08; 01/2010

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How does this health care pattern and nursing diagnosis relate to the primary diagnosis of this client?
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