Adult Health Assessment Form - NEED HELP WITH WORDING!!

Esme12, ASN, BSN, RN · Oct 11, 2012

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puppskmm · Oct 12, 2012

Jarvis has a small pocket guide that can be used separately or with the assessment book. It should help you with yorur adult pt.

kparker4 · Oct 14, 2012

SimChart Assessment

Neurological- Oriented to: time place situation confused alert disoriented unresponsive lethargic comatose semi-comatose
Emotions- Happy Calm Cooperative Uncoorperative Restless Anxious Combative Sad Crying Agitated Hostile Angry Distressed Withdrawn No eye contact Flat affect Labile
PERRLA- Pupil’s: Equal L- Round Reactive to Light Constricted Dilated R- Round Reactive to Light Constricted Dilated
Hand Grip- Equal Unequal: L/R L-Strong Weak R-Strong Weak
CNS Problems- Headache Syncope Seizures Tremors Vertigo Restlessness Tingling Numbing Nystagmus Affected side neglect (TIA/CVA) Coordination problems Purposeless movements Does not follow commands Does not move extremities on command Paralysis Localizes pain w/draws only from pain Decorticate posturing-flexion Decerbrate posturing-extension Flaccid
Vision Problems- Legally Blind Blind in L/R eye L/R Prosthesis L/R Unuclear Glasses Contacts No Vision Problems
Hearing Problems- Hard of Hearing L/R Hearing Aid Deaf No Hearing Problems
Speech Assessment- Garbled Non-verbal Receptive Aphasia Expressive Aphasia Clear Speech Incomprehensible Slurred
Apical Pulse- Regular Irregular

10. Left Radial Pulse- +4 Bounding +3 Normal +2 Palpable +1 Palp Weak 0 Absent Doppler Used

11. Right Radial Pulse- +4 Bounding +3 Normal +2 Palpable +1 Palp Weak 0 Absent Doppler Used

12. Left Dorsal Pulse- +4 +3 +2 +1 0 Doppler Used

13. Right Dorsal Pulse- +4 +3 +2 +1 0 Doppler Used

14. Left Post. Tib- +4 +3 +2 +1 0 Doppler Used

15. Right Post. Tib- +4 +3 +2 +1 0 Doppler Used

16. Capillary Refill- +3 sec -3sec

17. Edema- Non-pitting Pitting +1 Pitting+2 Pitting +3 Pitting +4 Weeping No Edema Present

18. Edema Location-

19. Mucous Membranes- Moist Dry

20. DVT Interventions- TED hose (knee high) TED hose (thigh high) SCD device in use Foot pumps in use Teach rationale for interventions

21. Respiratory Pattern- Even Unlabored Uneven Labored Deep Shallow Tachypenia Bradypenia Kussmaul

22. Breath Sounds- Clear: Bilaterally R/L

23. Crackles- Bilaterally R/L Fine Coorifice

24. Wheezes- Bilaterally R/L Inhalation Expiration

25. Rhonchi- Bilaterally R/L

26. Diminished Breath Sounds: Bilaterally R/L

27. Grunting Stridor

28. Respiratory Signs: Dyspnea/SOB SOB on expansion Increased chest expansion Orthopnea Uses accessory muscles

29. Oxygen in use: Y/N Amount of O2:_______(% or L/PM)

30. O2 Delivered via: Nasal cannula Venturi mask Non-rebreather mask O2 tent Entotracheal tube Tracheal tube Naso-pharyngeal tube Trans-tracheal

31. Blood Measurement: Continuous pulse ox in use Spot Pulse ox _______%

32. Lung Clearing: Receiving Nebulizer Treatments Uses incentive spirometer

33. Suctioning: Recieves periodic suctioning

34. Secretion Amount: Scant Moderate Copious Other

35. Secretion Color: Clear White Yellow Dark Yellow Tan Brown Green Blood-Streaked Bloody Other

36. Secretion Consistency: Thin Frothy Thick Other

37. Secretion Odor: None Foul Other

38. Cough: None Wet Dry Strength: Strong Weak Productive: Y/N

39. Range of motion- L/R arm and leg: Full Limited Immobile Contracted Flaccid

40. Gait- Steady Unsteady Bedfast

41. Post Op Area- R/L Foot R/L Ankle R/L Knee R/L Hip R/L Wrist R/L Shoulder R/L Elbow R/L Femur R/L Humorous

42. Post Op Assessment- Normal Cyanotic Mottled Reddened Warm Cool to Cold Brisk Capillary Refill Slow Capillary Refill No Edema Moderate Edema Marked Edema/Swelling; tissue tight Negative Homan’s sign Positive Homan’s sign Pain on Plantar Flexion No Pain on Plantar Flexion No Parathesia Noted Reports Numbness and Tingling Able to wriggle toes/fingers Unable to wriggle toes/fingers

43. Amputation Prosthesis

44. Oral Condition- Good Fair Poor Ulcers/Canker Sores Lesions Erythemia White Patches Mucositis

45. Esophageal Condition- No Swallowing Problems Tolerates Prescribed Diet Dysphagia Aphagia Reflux after Eating Reflux when Bending Over Frequent Heartburn

46. Teeth Condition- Good Fair Poor No Natural Teeth U/L Dentures None

47. Continent of Urine- Y/N

48. Urination Mode- Voiding Foley Straight Cath by Self Straight Cath by Nurse Urinary Diversion Anuric

49. Urine Description- Clear Cloudy Clots Visible Milky Sediments Visible Yellow (straw colored) Pale Yellow (Diluted) Dark yellow (Amber) Brown Color Green Brown Orange-Red Orange-Red, Tea Colored Red, Red-Brown Frank Blood No Odor Foul Odor Unusual Odor

50. Urinary Problems- No Problems Noted Bladder Distension Urine Retention Complains of pain/burning on urination Complains of urgency/hesitancy/frequency/stress incontinence Dysuria Oliguria Polyuria Nocturia Pyuria

51. A/V Fistula- Location Palpable thrill Auscultated Bruit

52. Foley Change Due- / /2011

53. Presence of Urinary Diversion

54. Presence of Peritoneal Diversion

55. Penile Assessment- No abnormal S/S Lesions Nodules Inflammation Swelling Smegma Genital Warts Dischage Noted (culture)

56. Scrotal/Testicular Assessment: No abnormal S/S noted

57. Female External Genital Assessment- No Abnormal S/S Lesions Nodules Inflammation Swelling Canchres Polyps Smegma Genital Warts Discharge Noted (Culture) Parasites Present (Describe)

58. Skin Assessment- W/in Normal Limits for Pt. Pale Cyanotic Jaundiced Dusky Flushed Erythmia Mottled

59. Skin Temperature- Warm Hot Cool Cold

60. Skin Turgor- Good Elasticity Poor Elasticity Fragile Tenting Edema

61. Skin Moisture- Dry Moist Clammy Diaphoretic

62. Skin Integrity- Skin intact, no breaks Surgical Wound Decubitis Lesions/Skin Tears

63. Pain- Y/N Location ______ Constant Intermittent 1-10___ Unable to report

64. Non-verbal cues: Moans Groans Grunts Cries Gasps Sighs Facial grimace Winces Teeth clenched Guarding Restless Irritable Anxious Inattentive W/drawn

65. Physiological Cues of pain: Increased BP Tachycardia Tachypnea Pupils dilated Vasoconstriction Diaphoresis

66. Quality of Pain: Piercing Stabbing Throbbing Dull Sharp Nagging Burning Shooting

67. Aggravated by: Movement Coughing Positioning Exercising Urination BM Other

68. Relieved by: Rest Exercise Heat Cold Guided imagery Massage Change of position Distraction

69. History of falls: Current admission due to fall/recurrent falls w/in past 6 months Y/N

70. Altered mental/behavioral status: Confused, agiated, impulsive, short-term memory, poor judgement, non-compliant Y/N

71. Visual/Communication Impairment: Blind, partially blind, other visual defects, expressive/receptive aphasia, hearing impaired Y/N

72. Elimination Problems: Incontinence, urgency, frequency, etc Y/N

73. Medication effects that may contribute to a fall: Pain meds, sedatives, anti-psychotics, diuretics, anti-HTN, laxatives, anti-coagulants Y/N

74. Anesthesia/Conscious sedation w/in past 24 hours: Has undergone surgery or procedure w/ the use of A/CS Y/N

75. Mobility problems or impaired proprioreception: Dizzy, poor balance, weak during ambulation or transfer, amputee or paralysis Y/N

76. Complete bed rest: Dr has ordered bed rest Y/N

77. Bedbound: Unable to get out of bed Y/N

78. Fall prevention education Encourage side rails Bed in low position Bed wheels locked Call light w/in reach Bedside table w/in reach Instructed to call nurse for assistance Increasing pt monitoring Non-skid footware available Offering toileting every 2 hours Offering toileting every 4 hours Bed Check/Chair Check alarm Person with pt (Name_______) Pt. located close to NS Safety belt when walking with assistance Wheelchair seatbelt being used Wedge in Wheelchair being used Geri-chair being used Night-light on

79. Restraints: Y/N

80. Bracelet Check: Allergy Risk Fall Risk Blood Bank Other

81. Pt Response to Safety Measures: Compliant w/ nursing regimen Non-Complient w/ nursing regimen Reports understanding of teaching Remains injury free

82. Universal precautions: Universal precautions in effect Handwashing per universal precautions Efforts to minimize cross-contamination Pt education to decrease spread of disease

83. Contact precautions: Contact isolation in place Sign on door per hospital protocol Gloves/gowns at door Masks at doors Foot coverings at door Pt education to decrease spread of disease

84. Respiratory Precautions: Respiratory isolation in effect Signs on door per hospital protocol Gown/gloves at door Masks at door Foot coverings at door Pt education to decrease spread of infection

85. Seizure precautions: Instructed to call for assistance Call bell w/in reach Bed in low position Bed locked Suction equipment in room PRN O2 order from MD

86. Droplet precaution: Droplet isolation in effect Signs on door per hospital protocol Gown/gloves at door Masks at door Foot coverings at door Pt education to decrease spread of infection

OB ASSESSMENT

87. Onset of Regular Contractions:

88. Last Exam: Time:

89. Dilation:

90. Effacement:

91. Pelvic Station:

92. Response to labor: Calm Fearful Anxious Tired Excited Irritable Depressed Moaning Intense

93. Pharmacologic Pain Management: PRN Analgesic/Narcotic Epidural IVP Subq IM Description:________________

94. Nonpharmacologic Pain Management: Childbirth Classes Support Person Breating/Relaxation Techniques Effectively coping with contractions Other__________________

95. Breasts: Symmetrical/Asymmetrical

96. SBE: Y/N Frequency

97. Inverted/Flat/Everted Nipples: R/L

98. Breast/bottle/both infant feeding

99. Fundal Height

Membranes: AROM, SROM, Meconium, Foul Odor Date/Time:
Sexual/fertility concerns
Birth Control Plan
Fetus: Lie: Presentation: Position:
Fetal Monitoring: EFM IUPC Electrode Baseline Fetal Heart Rate:
Variability: Absent Minimal Average/Moderate
Accels: Y/N Decels: Y/N

Post OB ONLY

Breasts: Symmetrical Asymmetrical Soft Filling Engorged
Fundus Position: Midline High To Side
Fundus Firmness: Firm Firms with Massage Boggy
Lochia Amount: Scant Moderate Heavy Fleshy Foul
Lochia Type: Rubra Serosa Alba
Perineum: Hemorrhoids Lesions Hemotoma Warts Swelling Varicosities Episiotomy/Laceration
Infant care classes Books Experience Help at home
Observed interaction with infant: Enface Enfolding Stroking Fingertip Talking
Blood Type: A B AB O

10. Rh: + -

11. Rhogam Given/date:

12. Estimated blood loss:

13. Hgb/Hct:

14. PPD Given/ Results:

Vitals, I&O, Height and Weight, Blood glucose

Temp: Site: Tympanic Oral Forehead Rectal
Pulse: Site: Radial Apical Pedal Moniter
Resp:
B/P: / Site: L/R Arm L/R Leg Moniter
B/P: Position: Lying Sitting Standing
O2 Sat: % Delivery Method: Room air 1lpm via NC 2lpm via NC 3lpm via NC
PO Type: PO fluids Ice chips Ensure Other Amount : mLs/oz
IV Fluids: Normal Saline D5NS D5 ½ NS IV fluids Amount: mLs
Misc Type: Irrigation Ensure Glucerna Other Amount: mLs/oz
Meals: Breakfast Lunch Dinner Snack Amount: %
Output type: Urine Stool Emesis HemoVac Penrose Jackson Pratt Other Amount: mLs/oz
Height: ____ In _____Ft _____cm
Weight: ______lb ______oz _______kgs _______grams
Metho d of weight: Standing Scale Bed Scale Pt statement Estimate
Blood glucose:
Labs:

Updated Pt data?

Pt teaching?
Medications?
Wounds, IV, Ostomies, Drains, Tubes, Injection sites?
Narrative charting

Pre Clinical Information

21. Admitted: Admitting Type: Admitting Office ED Clinic Dr Office Nursing Home Other

22. Arrived: Wheelchair Stretcher Ambulatory Other

23. Verbal Admission History Information Unavailable: Pt unable to respond

24. Informant/Historian: Pt Spouse Parent Significant Other Friend Family Member Old Charts Other Name:

25. Past Admissions: Last Hospital: Reason: Where:

26. Will family/other be staying with Pt: Y/N Name:

27. Who should we communicate with: Self Spouse Parent S/O Friend Family Member Other Name: Phone Number:

OB INFORMATION

28. Gravida:___________________ Term:______________________ Pre-Term_______________________

29. Abortions:_________________ LiveBirths:__________________

30. Expected Date of Delivery:______________ EDD Confirmed by U/S: Y/N Used Naegele’s Rule: Y/N

31. Current Weight:_________ Prepregnancy Weight:__________ Total Prenatal Gain:______________

32. Month of First Prenatal Visit:_____________________ Regular/Irregular

33. NVSD C/S VBAC Length of time since last pregnancy:____________________________

34. Diabetes Uterine Surgery Cancer Previous OB Problems PIH UTI/Kidney PP Hemorrhage STD Cardiac Anemia ABO/Rh Sensitivity Stroke TIA Paralysis Cerebral Palsy Epilepsy Fainting/Dizziness Neuro Problems Other:___________________

35. Previous Surgeries:____________________________________________________________________

36. Anesthesia Problems: __________________________________________________________________

37. Can you read? Y/N

38. Can you write? Y/N

39. Primary Language: English Spanish French Vietnamese Portuguese Chinese Japanese German Italian Polish Hungarian Russian Other

40. Need Translator: Y/N Name:

41. How do you prefer instructions? Written Spoken Demo Video/TV Other

42. Do you have challenges when learing? Y/N

43. Hearing problems Deaf L/R Ear Vision Problems Legally Blind Trouble Speaking Cant understand

44. Education level: Grade School Some High School Graduated HS Some college Graduated college Some Grad studies Graduated grad studies Other

45. Why were you admitted?

46. How long has this problem went on: Today Yday Few days Couple weeks Month Few months Chronic Problem Other

47. How have you cared for it:

48. Living will: Y/N

49. Advanced Directive: Y/N

50. Living Will/AD:

51. Visitor Restrictions:

52. Any known allergies: Y/N Medication Environment Food Type Severity Informant Confidence Entered by

53. Any meds, vitamins, suppliments at home: Y/N Name:_________________ Dose:__________________ Units:____________ Form: _______________ Frequency:__________________

54. Last flu vaccine: / / Never Interested in

55. Last pneumonia vaccine: / / Never Interested in

56. Tetorifice Vaccine: / / Never

57. Hepatitis Vaccine: / / Never

58. Recent exposure to TB: Y/N / / History of: Y/N Describe:

59. Recent exposure to infectious disease: Y/N / / Describe:

60. Travel: In the past 10 days have you or a close contact traveled w/in or outside the US: Y/N / / Where:

61. Smallpox vaccine: Pt. and Family Members Y/N / /

62. Order SPV Alert is pt/Fm has had vaccine:

63. Vaccine brochures given: Flu Y/N Pneumonia Y/N

64. Street/Rec Drug use: Never Currently Quit

65. Type of drug: Marijuana Cocaine Meth Heroin Ecstacy Pain Killers Amphetamines Anti-Anxiety Other

66. Amount per day:

67. Have you used w/in the past:

68. How long have you used: Less than a year 1-5 years 5-10 years More than 10 years Other

69. Plan to quit: No plans Thinking of quitting Preparing to quit

70. What is your quit date: / /

71. Care provider notified of positive screen: Y/N name:

72. When did you quit: / /

73. Drug use info given: Y/N

74. Do you live with a smoker: Y/N

75. Smoker Status: Never Currently Quit

76. What type of: Cigarettes Cigars Pipes Chewing Tobacco Snuff

77. How much tobacco do you use: A pack or less a day More than a pack a day 1-2/day 3-5/day More than 5/day One pipe/day 2-4 pipes/day More than 4 pipes/day Chew several times a day Dip several times a day

78. How long have you used: Less than a year 1-5 years 5-10 years More than 10 years Other

79. The following statement: No plans to quit Thinking of quitting Preparing to quit

80. What is your quit date: / /

81. Why do you want to quit: Health Social pressure Family pressure

82. What are your concerns: W/drawel Fear of Failure Weight gain Dealing with stress Habit

83. Do you plan to use a: No I don’t know Yes, a patch Yes, nicorette gum Yes, Nasal Spray

84. Why did you start using again: Never tried to quit before Couldn’t deal w/ cravings Stress was to much to handle Drinking Missed tobacco W/ other smokers, couldn’t resist Gaining weight Couldn’t break the habit in certain situations Trouble using the replacement products

85. When did you quit tobacco use: Less than 3 weeks ago More than 3 weeks ago W/in the last 6 months Longer than 6 mths ago 1-2 years 2-5 years Longer than 5 years

86. Temption triggers: Sitting at the table after a meal Seeing people smoking around me Automatically lighting a cigarette Drinking or socializing

87. Printed info given: Y/N

88. Do you drink alcohol: Y/N

89. How often do you: Daily Weekly Monthly Holiday/Special occasions only Other

90. How long have you been: Few weeks to a month Few months to a year 2-5 years 5-10 years more than 10 years other

91. When was your last: W/in 24 hours W/in 48 hours W/in 72 hours Week ago Month ago Other

92. Do you have a history of alcohol: Y/N

93. Have you felt that you should cut back on your drinking: Y/N

94. Have people annoyed you by critizing your drinking: Y/N

95. Have you felt guilty about your drinking: Y/N

96. Positive screen: Less than 72 hours since last drink, history of alcohol w/drawel OR pt history and less than 72 hours-Alert provider: Y/N Name:

97. Orders for PT: Y/N

98. No new PT problems noted: Y/N

99. There is a new problem that makes it difficult to stand w/o assistance: Y/N

100. There is a new problem that makes it difficult to walk safely withour assistance: Y/N

101. There is a new problem with losing balance: Y/N

102. There is a new problem with falling: Y/N

103. There is a new problem with moving from lying to sitting: Y/N

104. There is a new problem with moving from sitting to standing: Y/N

105. There is a new problem with moving from bed to a chair: Y/N

106. PT screen if 1 or more Y

107. Does pt have a condition/order that restricts participation in PT: N/Y Y=Medically cleared

108. New OT problems: Y/N

109. There is a new problem using arms or hands fully

110. There is a new problem that affects independence in toileting: Y/N

111. There is a new problem that affects independence in bathing: Y/N

112. There is a new problem that affects independence in dressing: Y/N

113. There is a new problem that affects independence in grooming: Y/N

114. There is a new problem that affects independence in feeding: Y/N

115. The pt safety awareness/judgement is impaired: Y/N

116. The pt is at risk of skin sores: Y/N

117. 1 or more positive findings, order OT screen

118. Does pt have a condition/order that restricts participitation in OT: Y/N

119. Speech therapy problems: Y/N

120. There is a new problem with slurred speech that makes it difficult for others to understand: Y/N

121. There is a new problem understanding what others are saying: Y/N

122. There is a new problem telling others about needs: Y/N

123. There is a new problem with swallowing that causes coughing or choking: Y/N

124. There is a new problem with weakness making chewing/swallowing difficult

125. There is a new trach tube and needs a speaking valve to communicate: Y/N

126. The Pt’s memory impaired: Y/N

127. The pt’s orientation to person, place or time in impaired: Y/N

128. Does pt have an order or condition that restricts ST: Y/N

129. Special dietary needs/problems: Y/N

130. Must follow special diet related to medical conditions

131. Food allergies

132. Stage 3 or 4 skin breakdown

133. Continuous vomiting or diarrhea greater than 24 hours

134. Poor appitite for more than 2 weeks

135. Unintentional weight change greater than 10 lbs in 3 mths

136. Pediatric growth chart below 25th % or above 95th %

137. Appearance of malnutrition/failure to thrive

138. Recent diagnosis of diabetes or uncontrolled diabetes

139. Chewing and/or swallowing is impaired

140. Diet prior to hospitalization:

141. Food preferences:

142. Food Dislikes:

143. After discharge will you be home with no assistance: Y/N

144. Will your medical problems cause a change in the ability to care for yourself: Y/N

145. Do you have any problems with coping, grief, or end of life issues: Y/N

146. Was the pt admitted from a nursing home or need to be placed in one: Y/N

147. Is the pt homeless or unID’d: Y/N

148. Have you been emotionally or physically abused by a partner or someone else: Y/N

149. Have you been hit, slapped, kicked or physically hurt by someone in the past: Y/N

150. Have you been forced into sexual activities: Y/N

151. Are you afraid of your partner or someone else: Y/N

152. Is there any person who threatens you or hurts you: Y/N

153. Are there physical injuries inconsistent with the pt’s history: Y/N

154. Have you been hospitalized more than twice in the past 3 months: Y/N

155. Do you currently use O2 or medical equipment at home: Y/N

156. Have you had any difficulty obtaining your medications: Y/N

157. Do you anticipate the need for home health services or medical equipment: Y/N

158. Do you anticipate the need for home infusion or enteral needs: Y/N

159. Was pt admitted from another hospital or other facility: Y/N

160. Do you anticipate the need for self-injections at home: Y/N

161. Are there other concerns that warrant a case manager consult: Y/N

162. Are there religious, cultural, or ethnic concerns we should consider while you are here: Y/N

163. Do you want clergy to visit you while you are in the hospital: Y/N

164. Religious preference: Baptist Catholic Church of Christ Episcopalian Methodist Presbyterian Jewish Mormon Jehovah’s Witness Scientology Buddhist Islam Other

165. Ability to respond to pressure related discomforts: No impairment-4-responds to verbal commands, no sensory deficit that limits ability to feel pain/discomfort Slightly limited-3- responds to VC but can’t always communicate discomfort back/has sensory impairment very limited-2-responds only to painful stimuli, can’t communicate/has sensory deficit completely limited-1-unresponsive

166. Degree to which skin is exposed to moisture: 4-rarely moist 3-occasionally moist 2-very moist 1-constantly moist

167. Degree of physical activity: 4-walks frequently 3-walks occasionally 2-chairfast 1-bedfast

168. Ability to change and control body position: 4-No limitation 3-slightly limited-frequent but slight body changes 2-very limited-occasional slight body changed 1-completely immobile

169. Usual food intake pattern: 4-excellent-most of every meal 3-adequate-eats over half of most meals 2-probably inadequate-rarely eats a complete meal 1-very poor- never eats a complete meal

170. Degree to which skin is at risk for friction or shear: 3-no apparent problem 2-potential problem 1-problem

171. Are you currently experiencing pain: Y/N -Y do pain assessment

172. Fall risk assessment

173. Organ donation: Donor card w/ witness Drivers license Not an OD but want to be Do not want to be OD

174. Type of organs: Needed Organs or Tissue Only organs and tissues listed:

175. Consent to treat form on file: Y/N

176. Instructed on: Call light ER light in BR Lights in room Bed controls Side rail policy Telephone TV control Meal times and snacks Visiting house No smoking policy Guest info Safety tips

177. Information given to: Pt Spouse Parent SO Friend Family Member

178. Unable to orient: Y/N

179. Bracelet check: Hospital ID band Latex allergy Other allergy Blood bank Fall risk Pressure sore risk Other allergies:

180. Printed info given: “The Patient Care Partnership” “An Important Message from Medicare” “Medicare and You” handbook “Living with Heart Failure” Street/Rec Drug Dangers brochure “Smoking Cessation” Alcohol abuse brochure “Managing Pain” “Blood/Blood Products” “Hospital Issued Notice of Non-Coverage” Organ Donation Advanced Directives for Healthcare Living Wills Durable POA for Healthcare Pneumonia Vaccine Info Flu Vaccine Info