Assessment

I. Current Job

A. What is your current job title? __________________________________________________________________________

B. How long have you had this job? ________________________________________________________________________

C. What specific tasks you perform on the job? ______________________________________________________________

____________________________________________________________________________________________________________

D. Are exposed on any of the following on your present job?

__Chemicals __Infectious agents __Stress

__Dusts __Loud Noise __Vapors, Gases

__Extreme __Radiation __Vibrations

Temperature changes:

E. Do you think you have any work-related problems?

If so, describe _______________________________________________________________________________________________

F. How would you describe your satisfaction with your job?

__Very satisfied __Satisfied __Somewhat satisfied __Dissatisfied __Very Dissatisfied

G. Have there been any recent changes in your job?

H. Do you use protective equipment/clothing on your job?

If so, list items used: ________________________________________________________________________________________

II. Pas Work Experience:

Please provide the following Information, starting with your first job:

Job Title Dates Hired Brief description of job Exposures Injuries/Illnesses

 HEALTH HISTORY

Name_______________________________________ Date______________________ Time_________________

Demographic Data:__________________________ Gender______________ Marital Status_____________

Reason for Seeking Health Care ____________________________________________________________________________________________

________________________________________________________________________________________________________________________

Previous Illness/Hospitalization/Surgeries:

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Client/Family Medical History:

Addiction (drugs/alcohol) ___________ Diabetes____________________ Mental Disorders_____________

Arthritis _________________________ Heart Disease_______________ Sickle cell anemia____________

Cancer___________________________ Hypertension_______________ Stroke______________________

Chronic Lung Disease______________ Kidney Disease______________ Other_______________________

Immunization/Exposure to Communicable Disease: ___________________________________________________________________________

Allergies________________________________________________________________________________________________________________

Home Medications:
________________________________________________________________________________________________________________________

Developmental Level:
________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Psychosocial History: Alcohol use: _________________________________________________________________________________________

Tobacco use: ____________________________________________________________________________________________________________

Drug use: _______________________________________________________________________________________________________________

Caffeine intake: _________________________________________________________________________________________________________

Self- perception/Self-concept: ____________________________________________________________________________________________

Sociocultural History: Family structure

Role in family ___________________________________________________________________________________________________________

Cultural Ethnic group ____________________________________________________________________________________________________

Occupation/work role ____________________________________________________________________________________________________

Relationships with others__________________________________________________________________________________________________

Activities of Daily Living:

Nutrition: Type of diet__________________________________________ Usual weight____________________________________________

Eating patterns __________________________________________________________________________________________________________

Type of snacks___________________________________________________________________________________________________________

Food likes/dislikes________________________________________________________________________________________________________

Fluid intake: Type______________________________________ Amount________________________________________

Elimination (usual patterns): Urinary________________________ Bowel__________________________________________

Sleep/rest:
Usual sleep patterns______________________________________________________________________________________________________

Relaxation tecniques/patterns______________________________________________________________________________________________

Activity/Exercise:

Usual exercise patterns____________________________________________________________________________________________________

Ability to perform self-care activities________________________________________________________________________________________

Review of Systems:

Respiratory_____________________________________________________________________________________________________________

Circulatory_____________________________________________________________________________________________________________

Integumentary___________________________________________________________________________________________________________

Musculoskeletal__________________________________________________________________________________________________________

Neurosensory____________________________________________________________________________________________________________

Reproductive/Sexuality____________________________________________________________________________________________________

Health Maintenance Activities:

Usual source of health care________________________________________________________________________________________________

Date of last exam (physical, dental, eye)______________________________________________________________________________________

Other health maintenance activities_________________________________________________________________________________________

Initial Nursing Patient Assessment
Admission Date: Room: Time:
___AM ___PM
How admitted: AmbulatoryWheelchair  Stretcher Ambulance Other
Accompanied by: Family Friend  Other
VITAL SIGNS ORIENTATION
Temperature: Height Call light/Bed control  Visitation Rules  Bed Locked 
Pulse: Weight (Actual) lbs. Television  Phone 
Respiration: Educational Channels  Bathroom/Emergency light 
BP: Lights  ID Band On 
PERSONAL ESSENTIALS LIST/ TRANSFER INFORMATION
Valuables to safe No Yes(list on valuables envelope only) Sent Home  Date/Room Date/Room Date/Room Date/Room
Essentials at bedside?: (check only those that apply)
Rings  Plain yellow metal  Yellow metal with stone
Plain white metal White metal with stone

Watch - Describe
Hearing Aid Left Right
 Eyeglasses Contacts Left  Right
Dentures Full: Upper  Lower  Partial:Upper  Lower
Other: (Wheelchair, prosthesis, cane, etc.)
Admission Sending RN Sending RN Sending RN
Receiving RN Receiving RN Receiving RN
ALLERGIES
No known allergies  Yes
Allergies: Type of Reaction:

HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERNNURSING DIAGNOSIS

1. Informant: Patient Family Member Unable to obtain

2. Present Illness/Current/Reason for Hospitalization:

Health Maintenance Altered

Noncompliance (Specify)

3. Date last admitted: Never admitted

4. Previous Hospitalization/Surgical Procedures:

Infection, Potential for

Injury, Potential for

5. Medical Diabetes Respiratory Disease Kidney Disease Mental Illness Other (Specify)
History: Hypertension Hepatitis Thyroid Disease Arthritis
Heart Disease Vision Disorder Neuro-Muscular DisordersSTD
Tuberculosis Seizure Disorder Problems with Anesthesia Other:
6. Medications: Including OTC Dugs/Treatment Used at Home

See Emergency Department Medication Review Sheet List Room Below if Patient not seen in Emergency Time Last Dose
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________
Insulin’s:____________________________________________ ___________________________
Transdermal:
7. Do you take your medications as ordered?  Yes  No Why?
____________________________________________________________________________
_______________________________________________________________________________________________________________________________________
8. Disposition of Medications:  Not Brought with Patient  Sent Home with Family  Sent to Pharmacy

9. Use of  Alcohol  Tobacco  Recreational Drugs  Alcohol  Tobacco  Recreational Drugs

How much? ________________________________________________ How long? _________________________________________________________
SYSTEM ASSESSMENTNURSING DIAGNOSIS
 Chest Pain Rhythm  Regular Radial  Palpable Dorsalis  Palpable Edema Present
 Orthopnea  Irregular Pulses:  Non-palpablePedis:  Non-palpable Pitting
 Hypertension Type :  Pounding  Other Other  Non-pitting
Vascular
Cardio-

 Pacemaker  Thready  Absent

 Apical Pulse  Weak
 Cough Chest  Symmetrical Breath  Labored Breath  Clear all lobes
 Productive Appearance:  Asymmetrical Patterned:  Non- labored Sounds:  Equal & Bilateral
 Non-productive  Crackles
ratory
Respi

 Dyspnea  Rhonchi
 Orthopnea  Wheezes
**1. Mobility Status:  Ambulatory  Ambulatory with Assist  Bed rest  Transfer with assist  Walker  Activity Intolerance
2. Assistive Devices:  None  Cane  Wheelchair  Crutches  Prosthesis  Pillows # ________  Airway Clearance Ineffective
 Other : _________________________________________________________________________________  Breathing Pattern Ineffective
3. Limitations:  None  Weakness  Fatigue  Other _______________________________________  Decreased Cardiac Output
_______________________________________________________________________________________  Activity Intolerance, Potential
4. Do you have enough energy for desired activity?  Yes  No Described: _______________________  Gas Exchange Impaired
Cardiopulmonary

_______________________________________________________________________________________  Home Maintenance

5. Activities of daily living: I= Independent A= Assist D= Dependent  Management, Impaired
_____ Feeding _____ Bathing _____ Grooming Describe ________________________  Physical Mobility, Impaired
_____ Toileting _____ Dressing _____ Other  Self Care Deficit, specify:
____________________________
 Other (specify) _____________
** Pain  Cramping Muscle Strength: (S= Strong W= Weak N= None)
Musculo

 Joint Stiffness  Spasms  Right  Left

skeletal

Grips:
 Swelling  Tremors Pushes:  Right  Left
-

** Headache Pain Pupil Size  PERL Level of  Alert Oriented to:  Person
Motor Disturbances  Other Consciousness:  Stuporous  Place
 Seizures  Semi comatose  Time
Neurological

Right ____________
 Numbness Left ____________ Comatose  Event
 Tingling  Combative
 Anxious
 Confused
**1. Visual Impairment:  None  Wears eyeglasses 4. Communication: Language/ Barrier  Yes  No  Pain
 Contacts 5. Level of Education: Grade: __________________  Pain Chronic
 Blind  Right  Left  Communication Impaired
2. Hearing Impairment:  None  Hard Hearing 6. Pain Discomfort:  Verbal
 Deaf _____ Right _____ Left Describe: ________________________________  Knowledge Deficit ( Specify)
 Uses hearing aid _____ Right _____ Left A. Precipitating Factors: ______________________________
3. Speech Impairment: Describe: ______________________________  Injury Potential for
 None  Cannot express ________________________________________  Sensory/Perception, Altered
 Slurring  Cannot understand B. How is pain controlled? (specify) _______________________
 Mute  Tracheostomy Describe: ________________________________  Thought Processes, Altered
 Stutters  Laryngectomy  Unilateral Neglect
 Other (Specify) ________________

 NormalTemperature:  Hot Describe:  Decubitus Bruises

 Pale  Warm  Rashes  Scars
Integumentary

 Flushed  Cool  Wounds  Not visible

 Cyanotic Turgor :  Good  Lesion  Others
 Jaundice  Fair
 Other  Poor
 Skin Intact
1. Special Diet  Yes  No  Body Temperature, Potential Altered
Describe: ________________________________________________________________________________  Fluid Volume Deficit
2. Frequency of Meals: Describe: ______________________________________________________________  Swallowing Impaired
3. Recent Changes in Appetite/ Eating/ Patterns? Yes  No  Infection Potential For
Nutritional / Metabolic

Describe: ________________________________________________________________________________  Nutrition: Less than Body

__________________________________________________________________________________________ Requirements, Altered
4. Have you experienced Indigestion  Vomiting  Difficulty Chewing  Choking with meals  Nutrition: More than Body
Current/recent  Nausea  Sore Mouth  Difficulty Swallowing  Full Feeling In Throat Requirements, Altered
Describe: ________________________________________________________________________________  Oral Mucous Membrane, Altered
5. Recent weight Loss/Gain?  Yes  No  Skin Integrity, Impaired
Describe: ________________________________________________________________________________  Skin Integrity, Potential Impaired
 Other (specify) __________________
HEALTH PATTERN ASSESSMENT

General  Well Nourished Oral  Dry Bowel  Present  Ostomies

Appearance:  Malnourished  Moist Sounds:  Absent  Gastrostomy
Intestinal

Mucosa
Gastro

 Obese  Nasogastric
 Jejunostomy
Patients at Risk to Develop Pressure Sores
Identify any patient at risk to develop pressure sores by assessing the seven clinical parameters and assigning a score. Patients with intact skin, but scoring 8 or greater,
should have the Nursing Diagnosis “Potential Impairment of Skin Integrity.” Directions: Choose the number which best describes the patient’s status total the seven
numbers.
Clinical Condition ParametersScore Clinical Condition Parameters Score Clinical Condition Parameters Score
General Physical Condition (Health Problem) Mobility (extremities) Skin/Tissue Status
Good (minor) 0 Full active range 0 Good (well nourished skin intact) 0
Fair (major but stable) 1 Limited movement with assistance 2 Fair (poorly nourished skin intact) 1
Poor (Chronic serious but not stable) 2 Move only with assistance 4 Poor (skin not intact) 2
Immobile 6
Level of Consciousness (to commands) Incontinence (bowel and bladder) Nutrition (for age and size)
Alert (responds readily) 0 None 0 Good (eats/drinks adequately - ¾ of meal) 0
Lethargic (slow to respond) 1 Occasional (less than 2x in 24 hours) 2 Fair (eats/drink inadequately at least ½ of
Semi- comatose( respond only to verbal or Usually (more than 2x in 24 hours) 4 meal) 1
Painful stimuli) 2 No control 6 Poor (unable/refuses to eat/drink less than
Comatose (no response to stimuli) 3 ½ meal) 2
Activity
Ambulant without assistance 0
Ambulant with assistance 2
Chair fast 4
Bed fast 6 Total

HEALTH PATTERNS ASSESSMENT NURSING DIAGNOSIS

Description per _____ Nurse _____ Patient
URINARY
GENITO-

Urine Color:  Clear  Hematuria  Bladder distension  Suprapubic Catheter

 Dark  Cloudy  Foley Catheter  Urostomy
 Other  Dialysis Access __________________
Description per _____ Nurse _____ Patient  Constipation
 Diarrhea
1. Bowel: No Problems  Diarrhea  Pain  Blood in stool  Incontinence, Bowel
 Constipation  Incontinence  Hemorrhoids Other  Incontinence, Functional
ELIMINATION

Describe: ____________________________________________________________________________  Incontinence, Total

2. Bladder: No Problems  Incontinence  Frequency  Burning  Nocturia  Urinary Elimination, Altered
 Retention  Dribbling  Dysuria  Urgency  Other  Urinary Retention
Describe: ____________________________________________________________________________  Other (specify)
3. Interventions:  None  Laxatives  Suppositories  Enemas  Other _______________________________
Describe: ____________________________________________________________________________ _
 Penile Discharge  Pain  Inguinal Mass  Penile Implant  Other  Role Performance, Altered
Male
REPRODUCTIVE

 Tenderness  Scrotal Mass  Breast Lumps  STD (Sexually Transmitted  Sexual Dysfunction
Diseases)  Sexuality Patterns, Altered
 Rape Trauma Syndrome
LMP ____________ Last Pap Smear : __________ Pain With: Pregnant:  Body Image Disturbance
 Itching  Breast Lumps Menstruation  Yes  Other ( Specify)
Female

Para ____________
Gravida _________  Abnormal Bleeding PMS  Intercourse  No
 Contraceptive  Discharge  Other
1. Home Environment:  Lives with spouse  Lives Alone  Lives with Family  Lives with friends  Communication Impaired
 Verbal
2. Who do you rely on for emotional support?  Spouse  Family  Friend  Self  Others  Family Processes, Altered
RELATION

Describe: __________________________________________________________________________________  Grieving, Anticipatory

 Parenting , Altered
ROLE

SHIP

3. How does your illness/hospitalization affect your family/significant others? Social Interaction
Describe: __________________________________________________________________________________  Social Isolation
1. Have you had recent changes in your life (job, move, divorce, death, major surgeries, and recent abuse)?  Violence, Potential for Self Directed
 Yes  No Describe: ______________________________________________________________________
COPING/

Or directed towards other

STRESS

2. Do you feel you are dealing successfully with stresses associated with this change?  Role Performance, Altered
Describe: __________________________________________________________________________________  Fear
 Other ( Specify) ________________
1. Sleep :  No problem  Difficulty falling asleep Difficulty staying asleep Does not feel rested after sleep  Sleep Pattern Disturbance
REST
SLEE

Other: _____________________________________________________________________________________  Other ( Specify)

P/

2. What helps you sleep? ________________________________________________________________________ ________________________________

1. What concerns you most about your illness/hospitalization?  Anxiety
Describe: __________________________________________________________________________________  Fear
PERCEP

2. Does your illness and/or hospitalization affect your sexuality/body image?  Yes  No  Powerlessness
TION
SELF

 Self- Esteem Disturbance

 Other (Specify) ________________
1. Is religion important in your life?  Yes  No  Religion/Faith : ___________________________________  Spiritual Distress
BELIEFS
VALUES

2. Do you have special religious request during this hospitalization?  Yes  No  Notify Volunteer Services  Other (Specify)
Describe: ________________________________________________________ for Clergy ________________________________

1. All areas with ** should be considered FPP.

SAFETY

2. FPP should automatically be instituted for pts who have / are: A. Fallen Previously
B. Confused, disoriented or combative
C. Chemical or Physical Restraints Required
 ADMISSION ASSESMENT
Date______ Time______ Baseline Data: Ht___Wt___T___P___R___BP___

Admitted from: Home___ER___Other___ Mode of Transport: Stretcher___W/___Amb____

Allergies__________________________ Home Meds: __________________ ___________________

__________________ ___________________

_________________ ___________________

Mental Status Comment Elimination Comment

Alert/Oriented Yes No _______________ GI: Constipation Yes No ___________

Confused  Yes No _______________ Frequency  Yes No ___________
Anxious  Yes No _______________ Laxatives  Yes No ___________
Comatose Yes No _______________
Combative Yes No _______________ Other______________________________________

Other_______________________________________________________ GU: Frequency Yes No ___________

Burning  Yes No ___________
Incontinent  Yes No ___________
Communication Comment
Other______________________________________
Speaks English  Yes  No _______________
Aphasic  Yes  No _______________ Sleeping Comment
Speech Impediment  Yes  No _______________
Unable to fall asleep Yes  No ___________
Sensory CommentAwakens frequently Yes  No ___________
Sleep med Yes  No ___________
Hearing Impaired Yes No ________________ Naps  Yes  No ___________
Visually Impaired Yes No ________________
Amputation Yes No ________________ ADL Comment
Hemiplegia Yes No ________________
Paraplegia Yes No ________________ Assistance needed for:
Diet/Nutrition Ambulation Yes  No ___________
Eating Yes  No ___________
Diet at home__________________________________________________ Bathing Yes  No ___________
Likes/Dislikes_________________________________________________ Dressing Yes  No ___________
Appetite_____________________________________________________ Eliminating Yes  No ___________
Turning Yes No ___________
Skin Location Other______________________________________
Warm/Dry □Yes  □No _________________ Dentures □Yes  □No ___________
Abrasions/Bruises □Yes □No _________________ Glasses □Yes  □No ___________
Laceration/Scar □Yes □No _________________ Contact Lens  □Yes  □No ___________
Reddened Areas □Yes □No _________________
Decubitus Ulcers □Yes □No _________________ Personal Habits:
Burns □Yes □No _________________ Tobacco use  □Yes  □No ___________
Rash/Scaling □Yes □No _________________ (quantity)
Diaphoretic □Yes □No _________________ Alcohol use  □Yes  □No __________

(quantity)Other________________________________________________________ Chief
Complaint_________________________________________
Color: Pale Normal Cyanotic ________________________________________________________
Treatments in Progress________________________________________ ________________________________________________________
____________________________________________________________ Other Assessment Data____________________________________