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Assessment

The document is an assessment sheet for patient data, including personal information, health history, and various medical evaluations across multiple systems such as skin, respiration, circulation, nutrition, elimination, comfort, and functional status. It also includes sections for medication, lab investigations, patient problems, nursing diagnosis, and a nursing care plan. This comprehensive format is designed to facilitate thorough patient assessment and care planning.

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mohamedhazem.py
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17 views8 pages

Assessment

The document is an assessment sheet for patient data, including personal information, health history, and various medical evaluations across multiple systems such as skin, respiration, circulation, nutrition, elimination, comfort, and functional status. It also includes sections for medication, lab investigations, patient problems, nursing diagnosis, and a nursing care plan. This comprehensive format is designed to facilitate thorough patient assessment and care planning.

Uploaded by

mohamedhazem.py
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Assessment Sheet

Student's name: - Group no:-


Section: -Date:-

Patient's Data :-
Patient's name: -Age: Sex:
Occupation:Weight:
Marital Status: -M( ) -W( ) -S( ) D( )
Admitted From:
Out Patient: ( ) - Emergency ( ) - Referred:( )
Diagnosis:
……………………………………………………………………………
……………………………………………………………………………
Health history :
1-Chief complain
:………………………………………........................................................
……………………………………………………………………………
2 –Past medical history:
……………………………………………………………........................
……………………………………………………………………………
3- Family history:
……………………………………………………………………………
……………………………………………………………………………

Skin
- Rash ( ) -Previous scare ( )
- Hot skin ( ) - Cold skin ( )
- Pale skin ( ) - Jaundice ( )
- Reddening of pressure areas ( )
- Skin ulceration / damage ( )

1
Respiration

A- Pattern of respiration:-
- Tachypnea ( ) - Bradepnea( ) - Shallow () - Deep ( )
Respiratory problems: -
Dyspenea:- on rest ( ) - on effort ( ) - Orthopnea ( )

- Cough:- dray ( ) - Wet ( )

-Sputum:- - Red ( ) - black( ) - yellow ( ) - Green ( )

- thick ( ) - Watery ( )- Offensive odor ( )


Amount: - small ( ) - Moderate ( ) - Large ( )
- Hemopttsis ( )

B – Air entry :
- Rt.Lung: - absent ( ) - Site:…………
- Lt. Lunge: - absent ( ) - Site …………
- Wheezes: - Rt. Lunge ( ) - Lt. Lunge: ( )
Crackles: - Rt. Lunge ( ) - Lt. Lunge: ( )

Circulation

Patient'scomplain : -
- Chest pain ( ) - Dizziness ( )
- Pitting edema ( ) - Delayed capillary refill ( )
- Cyanosis: - central ( ) - peripheral ( )

Food and Nutration

Patient'scomplain :
- Reduce tissue turgor ( ) - Drtay mouth ( )
- Coated mouth ( ) - Anorexia ( )
- Nausea ( ) - vomiting ( ) - Abdominaldistension ( )
- Ordinary diet ( ) - Special diet ( ) - type:
- Method of feeding:
- Oral ( ) - nasogastric ( ) - Parental ( )

2
Elimination
A- Bowel elimination :
- Incontinence ( ) - Diarrhea ( ) - constipation ( )
- Fecal impaction ( ) - Melena ( ) - Others ( )

B- Urinary elimination :
-Retention ( ) - Incontinence ( ) - Urgency ( )
- Frequency ( ) - Dysuria ( ) - -Polyuria ( )
- Oliguria ( ) - Catheterized ( ) - Others ( )

Wound

-Present ( ) - Absent ( )
- Site: ……………………………………………………………………
- Type:
- Open ( ) - Closed ( )
- Clean ( ) - Septic ( )
-Drain:
- Present ( ) - Absent ( )
- Color of discharge:………………………………………….
-Amount of discharge: ………………………………………

Comfort and Sleep


A-Pain
- Present ( ) -Absent ( )

If present
- Precipitating factories:…………………………………………..

- Quality:
-Stabbing ( ) -Burning () -Pricking ( ) -Aching ( )
- Cramping () -Pressing ( ) –Squeezing ( )

- Region/Radiation:............................................................................
-Severity: - Miled ( ) -Moderate ( ) -Sever ( )
-Time: - Continuous ( ) - Intermittent ( )

B- Insomnia :
- Present ( ) - Absent ( )

3
Functional Status

A-Energy level:

- Exhausted without activity ( ) -Tires easily ( )


- Activity of daily living: - Dependant ( ) - Independent ( )
- Needs assistant with:Eating ( ) - Dressing ( ) - Bathing ( )

B- Mobility status:

-Immobile ( ) - Mobile with assistance of other person ( )


- Mobile with device ( )
- Cratch ( ) - Wheel chair ( ) - walker ( )
-Physical handicapped ( ) .............................................

Neuromuscular

A-Patient's complain :
- Headache ( ) - Paraethesiae ( )
- Lethargic ( ) -Disoriented ( )
-Slurred speech ( ) - Dysphasia ( )

B- Limbs :
Weakness ( ) - Flaccid ( )
- Joint stiffness ( ) -Muscular pain ( )

4
Medication

Name of Dose route Main action Nursing role


medication

Lab. Investigation
:

Name of investigation Patient value Normal value

5
Patient problems

Actual: Potential:

........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

..........................................................................................................................................................
..
.............................................................................................................................................................

.............................................................................................................................................................

...............................................................................................................................................................

Nursing Diagnosis

.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................

6
Patient's Record

Patients name Bed No:


Date of admission:
Diagnosis: R.No:
Department :

Date Vital Singes Intake Out Put M

Time T/ P R B.b Oral IV Urine Drain Vomiting Stool


c b/min c/min mmhg Type Am type Am

- Balance= intake – out put


- Student signature

7
Nursing Care Plan

Nursing Patients Nursing Rational Evaluation


Diagnosis Goals intervention

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