nursing assessment final ppt

VII. NURSING ASSESSMENT

A.)NURSING SYSTEM REVIEW CHART NAME of PATIENT: Jamisola, Shairalyn Date: June 23, 2014 Area: Out Patient DepartmentPulse: 92bpm RR: 22cpm Temp: 38.00C BP: 120/80mmHg Weight:

B.) NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE

COMMUNICATION [ ] hearing loss [ ] visual changes[ ]denied

[ ] glasses [ ]languages[ ] contact lens [ ] hearing aide R LPupil size: 3mm [ ] speech difficultiesReaction: Pupil Equally Round Reactive to Light and Accommodation

OXYGENATION[ ]dyspnea [ ]smoking history none[ ] cough[ ]sputum[ ]denied

Resp. [x]regular [ ]irregularDescribe: bronchovesicular breath sounds heard over lungs; RR; 22cpm R:symmetrical to Left lung upon expansionL:symmetrical to Right lung upon expansion

CIRCULATION[ ]chest pain [ ] leg pain[ ] numbness of extremities[ ] denied

Heart rhythm [X] regular [ ] irregularAnkle Edema: non-pitting edema Carotid Radial Dorsal Pedis FemoralR +2 +2 +1 +2 +2L +2 +2 +2 +2 +2Comments: all pulses are palpable*if applicable: not applicable

Comments: no verbal cues

Comments: no subjective cues


NUTRITION: Diet: Diet As Tolerated [ ] N [ ] V Character:[ ] recent change in Weight and appetite[ ] swallowing difficulty[ ]denied

[ ]dentures [X]none Full partial with patientUpper [ ] [ ] [ ]Lower [ ] [ ] [ ]

ELIMINATION:Usual bowel pattern [x] urinary frequency Once a day >10 x per day[ ]constipation [ ]urgencyRemedies: [ ]dysuria None [ ] hematuriaDate of last BM [ ] incontinence Not remembered [ ]polyuria[ ] diarrhea character [ ] foley in place None [ ] denied

Comments: None.

Bowel sounds: normoactive

Abdominal Distention: Present [ ] yes [X] No Urine* (color, Consistency, odor) : Yellowish, aromatic *if foley balloon catheter Is in place none

MGT. OF HEALTH & ILLNESS:[ ] alcohol [x]denied(Amount, frequency): no subjective cues[ ] SBE: none Last Pap smear: noneLMP: none

Briefly, describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). N/A


SKIN INTEGRITY: [x] Dry [ ] Itching [ ] other [ ] denied

[X] dry [ ]cold [ ] pale[ ] flushed [X]warm [ ] moist [ ]cyanotic*rashes, ulcers, decubitus (describe size, location, drainage) No abnormalities noted

ACTIVITY/SAFETY: [ ] convulsion[ ] dizziness[ ] limited motionof joints[x] ambulate[x] bathe self[ ] other[ ] denied

[ ] LOC and Orientation: Patient is conscious and oriented to time and space. [ ] Gait [ ] walker [ ] care [] others[X] steady [ ] unsteadySensory and motor losses in face or extremities: No sensory and motor losses in face or extremities noted [ ] ROM limitations: limitation range of motion to move because of the IV site,

COMFORT/SLEEP/AWAKE:[ ] pain (location) frequencyremedies)[ ] nocturia[ ] sleep difficulties[ ] denied

[ ] facial grimace[ ] guarding[ ] other signs of pain: none [ ] side rail release form signed (60 + years) N/A

COPING:Occupation: StudentMembers of household: membersMost supportive person: parents

Observed non-verbal behavior: nonePerson (Phone Number): denied




A.)NURSING SYSTEM REVIEW CHART NAME of PATIENT: Jamisola, Shairalyn Date: June 25, 2014 Area: Emergency RoomPulse: 81bpm RR: 21cpm Temp: 36.90C BP: 90/70mmHg Weight:

B.) NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE

COMMUNICATION [ ] hearing loss [ ] visual changes[ ]denied

[ ] glasses [ ]languages[ ] contact lens [ ] hearing aide R LPupil size: 3mm [ ] speech difficultiesReaction: Pupil Equally Round Reactive to Light and Accommodation

OXYGENATION[ ]dyspnea [ ]smoking history none[ ] cough[ ]sputum[ ]denied

Resp. [x]regular [ ]irregularDescribe: bronchovesicular breath sounds heard over lungs; RR; 21cpm R:symmetrical to Left lung upon expansionL:symmetrical to Right lung upon expansion

CIRCULATION[ ]chest pain [ ] leg pain[ ] numbness of extremities[ ] denied

Heart rhythm [X] regular [ ] irregularAnkle Edema: non-pitting edema Carotid Radial Dorsal Pedis FemoralR +2 +2 +1 +2 +2L +2 +2 +2 +2 +2Comments: all pulses are palpable*if applicable: not applicable

Comments: no verbal cues



NUTRITION: Diet: Diet As Tolerated Except Dark Colored Foods[X ] Nausea [ x] Vomiting Character:[ ] recent change in Weight and appetite[ ] swallowing difficulty[ ]denied

[ ]dentures [X]none Full partial with patientUpper [ ] [ ] [ ]Lower [ ] [ ] [ ]

ELIMINATION:Usual bowel pattern [x] urinary frequency Once a day >10 x per day[ ]constipation [ ]urgencyRemedies: [ ]dysuria None [ ] hematuriaDate of last BM [ ] incontinence July 24,2014 [ ]polyuria[ ] diarrhea character [ ] foley in place None [ ] denied

Comments: None.

Bowel sounds: normoactive

Abdominal Distention: Present [ ] yes [X] No Urine* (color, Consistency, odor) : Yellowish, aromatic *if foley balloon catheter Is in place none

MGT. OF HEALTH & ILLNESS:[ ] alcohol [x]denied(Amount, frequency): no subjective cues[ ] SBE: none Last Pap smear: noneLMP: none

Briefly, describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). N/A

Comments: “Nag suka ko”

SKIN INTEGRITY: [x] Dry [ ] Itching [ ] other [ ] denied

[X] dry [ ]cold [ ] pale[ ] flushed [X]warm [ ] moist [ ]cyanotic*rashes, ulcers, decubitus (describe size, location, drainage) No abnormalities noted

ACTIVITY/SAFETY: [ ] convulsion[ ] dizziness[ ] limited motionof joints[x] ambulate[x] bathe self[ ] other[ ] denied

[ ] LOC and Orientation: Patient is conscious and oriented to time and space. [ ] Gait [ ] walker [ ] care [] others[X] steady [ ] unsteadySensory and motor losses in face or extremities: No sensory and motor losses in face or extremities noted [ ] ROM limitations: limitation range of motion to move because of the IV site,

COMFORT/SLEEP/AWAKE:[ x ] pain (abdominal area)(location) frequencyremedies)[ ] nocturia[ ] sleep difficulties[ ] denied

[ x ] facial grimace[ ] guarding[ ] other signs of pain: none [ ] side rail release form signed (60 + years) N/A

COPING:Occupation: StudentMembers of household: membersMost supportive person: parents

Observed non-verbal behavior: nonePerson (Phone Number): denied




nursing assessment final ppt

Documents