Nursing Assessment Form

NURSING ASSESSMENT FORM Patient name:______

1. CLINICAL DATA Age______Height ______Weight ______(Actual/Approximate) Temperature ______Pulse: ____Bounding ____ Normal ____Thready ____ Absent Pulse: _____Regular ____ Irregular Blood Pressure: Right Arm ______Left Arm _____ Sitting _____ Lying ______2. RESPIRATORY/CIRCULATORY Rate ______Quality: _____ WNL _____ Shallow _____ Rapid _____ Labored _____ Other ______Cough: ______No ______Yes/Describe ______Lungs: Upper rt lobes _____ WNL _____ Decreased _____ Absent _____ Abnormal sounds Upper lt lobes _____ WNL _____ Decreased _____ Absent _____ Abnormal sounds Lower rt lobes _____ WNL _____ Decreased _____ Absent _____ Abnormal sounds Lower lt lobes _____ WNL _____ Decreased _____ Absent _____ Abnormal sounds

Heart: ____Regular ____Irregular ____Extra heart sounds ____Murmurs: Describe: S1____Normal ____Accentuated ____ Diminished S2 ___Normal ____Accentuated ____Diminished Right Pedal Pulse: _____Bounding ____ Normal ______Weak ______Absent Left Pedal Pulse: _____ Bounding _____Normal ______Weak ______Absent Left Foot Color: _____Normal _____Pale ____Rubor Right Foot Color: ____Normal _____Pale ____Rubor 3. METABOLIC-INTEGUMENTARY Skin: Color: ____ WNL ____ Pale ____ Cyanotic ____ Ashen ___ Jaundice ____ Other ______Temperature: ____ WNL ____ Warm ____ Cool Turgor: _____ WNL ______Poor Edema: _____ No ______Yes/Description/Location______Lesions: _____ None _____ Yes/Description/Location______Ulcers: _____ None _____Yes/Description/Location______Bruises: _____ None _____ Yes/Description/Location______Reddened: _____ No ____Yes/Description/Location______Pruritus: _____ No _____ Yes/Description/Location______Tubes: Specify ______

MOUTH: Gums: _____ WNL ______White plaque ______Lesions _____ Other ______Teeth: _____ WNL ______Dentures: Other______ABDOMEN: Bowel Sounds: ______Hyperactive _____ Normal ______Hypoactive ______Absent ELIMINATION: Bowel Movements: ______WNL _____ Constipation _____Diarrhea _____Colostomy____ Other:______GENITOURINARY: Voiding: _____WNL Describe: color______clarity______Other:______Incontinence: ____ Present _____Absent ______Dysuria _____Urgency _____Frequency Catheter: Specifiy:______Urinary diversion: Specify______Subprapubic area: ____Soft ____Distended _____Hard 4. SENSORINEURAL Pupils ______Equal _____ Unequal If unequal, Left - size in mm. ______If unequal, Right - size in mm. ______Wears: ____ glasses ______hearing aide(s) _____ Reactive to light: Left: ______Yes ______No/Specify ______Right: ______Yes ______No/Specify ______Eyes: ____ Clear _____ Draining ______Reddened _____ Other ______Level of Consciousness: Alert: _____Yes _____ No Oriented to: Person ____Yes ____ No Place: ____Yes ____No Time: ____Yes ____No 5. MUSCULOSKELETAL Range of Motion: ______Full _____ Decreased Other: ______Balance and Gait: ______Steady ______Unsteady Hand Grasps: _____ Equal _____ Strong _____ Weakness/Paralysis ( ___ Right ____ Left) Leg Muscles: _____ Equal _____ Strong _____ Weakness/Paralysis ( ___ Right ____ Left) DISCHARGE PLANNING Lives: Alone ______With ______No known residence ______Intended Destination Post Discharge: _____ Home _____ Long-term care ______Homeless shelter _____ Boarding home______Undetermined _____ Other ______Previous Utilization of Community Resources: ____ Home Care/Hospice ____ Adult Day Care ____ Church Groups ____ Other ______Meals on Wheels ____ Homemaker/Home Health Aid ____ Community Support Group

Post-discharge Transportation: ______Car ______Ambulance ______Bus/Taxi ______Unable to Determine at this time

Anticipated Financial Assistance Post-discharge? _____ No _____ Yes ______

Anticipated Problems with Self-care Post-discharge? _____ No _____ Yes ______

Self-care abilities: Needs help with: _____feeding _____bathing _____dressing _____ grooming _____transferring _____taking medications _____cooking _____transportation _____using phone _____ shopping Assistive Devices Needed Post-discharge? _____ No _____ Yes Type: ______

Referrals: (record date) Discharge Coordinator ______Home Health ______Social Service ______Financial counselor______

Other Comments: ______

Signature: ______