Clinical Assessment 8 Page Sample

C.S. MOTT COMMUNITY COLLEGESCHOOL OF HEALTH SCIENCES

CLINICAL ASSESSMENT FORM: FIRST YEAR

Instructions:

1. Include as much information about the client as possible, based on subjective data (interviewwith client) and objective data (from Kardex, chart, care plan, and physical assessment of client).

2. Treat this like an ADMISSION ASSESSMENT.

3. It is permissible to use a potential problem (At Risk for…) for the NANDA diagnoses or to state NO diagnosis (if no problem is identified in a section).

4. Describe what you see, hear, feel, and smell as you do your assessment, using descriptive terminology.

5. All meds on the client's orders/clinical focus should be on this assessment somewhere. For each medication, give dose and frequency.

6. Do not leave any of the spaces blank, but indicate the reason you are unable to assess (i.e. Info.not available (INA) = information pertains to this client, but is not available or NA = information is not applicable to this client).

7. HIGHLIGHT WITH COLORED MARKER ABNORMAL FINDINGS THRU OUT THIS FORM.

8. Keep all assessments and care plans for your own future reference and have available upon request for future instructors.

9. The term RANGE refers to the previous 24 hour values for this client.10. ALL information obtained on this form MUST be kept confidential.

Client's Initials__FP____ Age_58____ Gender __M___ Student Name Bill Young

Client's Room Number_817-2_____ Date of Assessment 4/11/2014

Admitting Diagnoses & Date Pneumonia 4/8/2014

Current Surgical Procedures & Dates X-ray (Pneumonia) 4/8/14

Prior Health History within past 5 years (surgeries, injuries & medical conditions) CAD, CHF, MI, HTN, Obesity, Sleep Apnea, DM Type 2, Cellulites, Anemia, Lymphedema, & Neuropathy

Medications Prior to Admission (including prescriptions, OTC, and herbal medications) hydrocodone –acetaminophen, dextromethorphan guaifenesin, Nitroglycerin, Insulin NPH, Alprazolam, Metformin, Albuterol Sulfate, Digoxin, Folic Acid,Atenolol, Potassium Chloride ED, Allopurinol,Isosorbide Mononitrate ER, Aspirin, Amlodipine, Hydrochlorothiazide,Bumetanide, Atorvastatin, Trazodone, Niacin ED, Ceftriaxone, Azithromycin, & Clopidogrel

Family History (specify conditions and relationship to client) Father died of CHF @ age 78, Mother died of Diabetes @ age 85

Allergies (list & state reactions):

Drug: Demerol, Dilaudid, & Morphine , Vancomycin Food: None Environmental: None Latex: None Other Allergies impacting clients care at this time: None

Code Status/Advanced Directives Full Code

Current Adult Immunizations (i.e. pneumococcal, influenza, DT, hepatitis, MMR, Meningococcal): INA

Nutritional Assessment:

Diet/tube feeding 1800 Calories Swallowing/Mastication Swallows and Chews w/o difficultly

% eaten per meal 100% Condition of oral cavity Smooth, Pink, Moist, 32 teeth in good repair

Actual weight 340lbs Serum Albumin 2.7Actual height 69” Hgb 13.3 Hct 41.1% WBC 8,700 Platelets 230,000

Ideal weight for height 149-170 Serum Mg+ INA K+ 3.9 Ca+ 8.8 Na+ 137Recent weight gain/loss lost 6 lbs Serum Glucose Range 303-349

IV Access Devices (central or peripheral)_peripheral___________________ Sites Left Arm

Primary IV solutions with additives, and rate NS 0.9% 155mL/hr

Current or Prior (specify) Nutritional Problems, including food intolerances DM Type II, obesity

Nutritional Medications/Supplements Insulin NPH, Metformin, Potassium Cholride ED ,

Other Labs/Diagnostic Studies None

NANDA Nursing Diagnoses pertinent to ABOVE abnormal findings with R/T:

Imbalanced nutrition: more than body requirements R/T Excessive intake of nutrients as evidenced by DM Type II

Integumentary Assessment:

Braden/Norton Scale Score 21 / 23 Hair Full, Thick, Black HairSkin turgor No tenting Nails Pink, cap refill <3 secondsSkin temp Warm, Moist, with lesions Lesion description Cellulites open lower left leg

Skin color changes None Scar description Superior Chest (Heart Surgery)

Mucous membranes pink, moist, Nose- open, patient Wound location/description Cellulites lower left leg

Temperature Range 95.4F – 97.2F Wound measurements 3cm x 4cm

Additional Symptoms Cellulites right and left lower left leg, Edema

Prior History Cellulites, Edema

Integumentary Medications/Treatments (be specific) Hydrochlorothiazide 12.5mg TAB PO Daily 0600,Bumetanide 2mg TAB PO Daily 0600.


Impaired Skin Integrity R/T inflammation and infection of skin as evidence by Cellulites

<k/nursing.assessment.form_2002_first.year> Page 2 of 9 NCPC/jh, revised 3.11.2002

GI Assessment:

Bowel sounds Present & Active all 4 quadrants Abd. palpation results soft non-tenderBowel pattern Daily BM Last bm_4/11/14 description Formed Med. SizeAbd. percussion results Tympanic Drainage devices/output none

Additional Symptoms unknown

Prior History unknown

GI Medications none

Other Labs/Diagnostic Studies none


No NANDA

Renal Assessment:

Input Output UA results INA8 hour I & O total: 600 800 BUN_25____ Creatinine_0.75_____24 hour I & O total: 1600 1700 Urine Culture/Sensitivity INAUrine description Pale yellow, light odor Continence/Incontinence ContinenceDrainage devices None

Additional Symptoms INA

Prior History Lymphedema

Renal Medications Hydrochlorothiazide 12.5mg TAB PO Daily 0600, Bumetanide 2mg TAB PO Daily 0600

Other Labs/Diagnostic Studies INA


Excessive Fluid Volume R/T Congestive heart failure as evidence by increased pulmonary congestion


Cardiovascular Assessment: Heart sounds (specify) INA wears Life Vest Carotid Bruits noneB/P range 151-116 / 77 -63 Capillary refill <3 secondsPulse range 73 -88 Edema Lower Legs (R) +1, (L) +1Peripheral pulses Radial (R) +3, (L) +3, Pedal (R) +3, (L) +3

Homan’s Sign INACholesterol INA HDL_INA_ LDL_INA Trig INA

Pulse deficits INA wears Life Vest

Additional Symptoms CAD, CHF, MI, HTN Irregular Heart Rhythm

Prior History CAD, CHF, MI, HTN Irregular Heart Rhythm

Cardiac Medications Nitroglycerin (1/150)0.4mg TAB Sublingulal PRN, Digoxin 250mcg TAB PO BID, Atenolol 25mg TAB PO Daily 0900, Isosorbide Mononitrate ER 30mg TAB PO Daily 0900, Amlodipine 10mgTAB PO Daily 0600, Atorvastatin 5mg TAB PO Daily HS, Niacin ED 1,000mg TAB PO Daily HS, Clopidogrel 75mg TAB PO Daily 0900

Other Labs/Diagnostic Studies INA


Decreased Cardiac Output R/T Altered Heart Rhythm

Respiratory Assessment:

Breath sounds Crackles lower Lungs (Bi-Lat) Resp Tx Pneumonia SpO2/pulse ox 95% on Room Air Incentive Spirometer, max. vol inspired: _2000___Respiratory rate range 16-20 Cough Present Sputum description NoneRhythm Steady, Regular Sputum culture/sensitivityChest excursion Equal Bilaterally Chest x-ray See BelowAccessory muscle use none ABGs: pH_INA CO2 25_ HCO3 INA O2 sat INA

ABG Interpretation INA

Additional Symptoms Pneumonia, Sleep Apnea

Prior History Pneumonia, Sleep Apnea

Respiratory Medications Ceftriaxone 1g IV Q12H, Albuterol Sulfate 90mcg/2 puffs Inhalant Q6H

Respiratory Devices/Settings (i.e. O2) None

Other Labs/Diagnostic Studies Impression: CHF with pulmonary edema


Ineffective Breathing Pattern R/T history of Pneumonia as evidence by fatigue, shortness of breath


Neuro/Muscular Assessment:

Glascow coma rating 15/15 Speech Clear, appropriate to situationPERRLA Black, equal in size, Constrict (3mm), accommodate Gait fluid, steady, normal ROMLOC AO X 4 Distance amb 500+ feetOrientation (specify) aware of surroundings Assistive Devices NoneShort-term memory deficits None ROM FullLong-term memory deficits None Weaknesses None

Additional Symptoms None

Prior History None

Neuro/Muscular Medications None

Other Labs/diagnostic Studies None


No NANDA

Sexuality/Reproductive Assessment:

Female MaleAge @ menarche LMP Testicular Self-Examination (TSE) practiced monthly

Breast Self-Examination (BSE) practiced Last prostate 1 year agoLast pelvic & pap Last Prostate-Specific Antigen (PSA) value INALast mammogram Circumcised Yes (at birth)Marital status/Significant other Marital status/Significant other Single


Prior History None

Sexuality/Reproductive Medications None



No NANDA


Cognitive/Psychological Assessment:

Level of education Some College (1 year) Ability to relate to others Active social lifeProfession/job Bar/Pub Owner Psych History: NoneAffect Appropriate to situation Body image Desire to lose weight & become healthier

Additional Symptoms Anxiety

Prior History Anxiety

Cognitive/Psychological Medications Alprazolam 0.5mg TAB PO Daily

Substance Abuse (type, duration, frequency, last use) Denies



Stress Overload R/T Repeated Stressors as evidence by Chronic Illnesses

Perceptual Assessment: (describe technique used and findings) Visual corrected 20/20 Auditory Intact, Able to spoken & whispered words

Corrective devices Wears reading glasses Corrective devices NonePain rating scale (intensity) - 0 0-10 scaleIf pain present: location - None duration - None quality - None contributing factors - None relieving factors - None


Prior History None

Perceptual Medications None


________________________No NANDA___________________________________________________

______________________________________________________________________________


Activity/Self Care/ADL Assessment: Bathing Independent Amb. IndependentFeeding Independent Toileting IndependentCooking/cleaning Independent Safety Precautions (specify) NoneADL Assistive Devices None

Additional Deficits None

Prior History of Deficits None


No NANDA

Sleep/Rest Assessment: # hours slept per night @ home 6 hours # hours slept per night @ hospital 3 hoursSleep aids None Naps None# of pillows used 1 pillow HS confusion None

Additional Symptoms Sleep Apnea

Prior History of Problems Sleep Apnea

Sleep/Rest Medications (Prescribed and OTC) None


Sleep deprivation R/T inability to breathe during sleep as evidence by Sleep Apena

Stressor Assessment: (list stressors in each category) Financial None Cultural NoneFamily None Spiritual NonePsychological None Health Desire to become healthier

Additional Symptoms or pertinent information None

Prior Stressors Loss of brother @ age 18 (Cancer) & other brother @ age 40 suicide

Stressor Medications/Alternative Measures Desire to exercise for healthier lifestyle


Stress Overload R/T Repeated Stressors as evidence by Chronic Illnesses


Actual OR Anticipatory Discharge Planning Assessment:

Education Required Implemented deep breathing techniques . .

Implemented Incentive Spirometer

Scripts Required See Attached Sheet

Agency Referrals YMCA for weight loss

Follow up DR. Appts 1 week for lung assessment and medication review

Durable Medical (DM) Equipment Needed None

Outpatient Follow-up Lab Work None

Outpatient Follow-up PT/OT/ST/RT None

Community Resources (i.e. Meals on Wheels, WIC, Support groups, etc) None


Activity Intolerance R/T exertional dyspnea as evidence by decreased lung function

Prioritize THE TOP THREE NANDA Nursing Diagnosis for this client, based on Maslow’s hierarchy of needs:

1. Ineffective Breathing Pattern R/T history of Pneumonia as evidence by fatigue, shortness of breath

2. Decreased Cardiac Output R/T Altered Heart Rhythm

3. Excessive Fluid Volume R/T Congestive heart failure as evidence by increased pulmonary congestion


hydrocodone –acetaminophen 7.5/325mg TAB PO Q6H PR PAIN

dextromethorphan guaifenesin 10/mL Syrup PO Q4H PRN Cough suppressant

Nitroglycerin (1/150)0.4mg TAB Sublingulal PRN Chest Pain

Insulin NPH Reg 70/30 100 units/1mL SQ BID Diabetes

Alprazolam 0.5mg TAB PO Daily Anxiety

Metformin 1,000mg TAB PO BID Diabetes

Albuterol Sulfate 90mcg/2 puffs Inhalant Q6H Bronchodialtor

Digoxin 250mcg TAB PO BID CHF

Folic Acid 1mg TAB PO @ Daily 1300 Cell Development

Atenolol 25mg TAB PO Daily 0900 Chest Pain (angina)

Clopidogrel 75mg TAB PO Daily 0900 CAD

Potassium Cholride ED 10meq TAB PO Daily 0900 Low Potassium Level

Allopurinol 300mg TAB PO Daily 0900 treat hyperuricemia (excess uric acid in blood plasma)

Isosorbide Mononitrate ER 30mg TAB PO Daily Angina

Asprin 325mg TAB PO Daily 0900 Pain

Amlodipine 10mgTAB PO Daily 0600 Hypertension & CHF

Hydrochlorothiazide 12.5mg TAB PO Daily 0600 Edema (Diuretic)

Bumetanide 2mg TAB PO Daily 0600 Edema (Diuretic)

Atorvastatin 5mg TAB PO Daily HS high cholesterol

Trazodone 150mg TAB PO Daily HS antidepressant

Niacin ED 1,000mg TAB PO Daily HS

Ceftriazone 1g IV Q12H Pneumonia

Azithromycin 250mg IV Q24H Infection

Clopidogrel 75mg TAB PO Daily 0900 CAD (blood clots)


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Clinical Assessment 8 Page Sample