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I.

VITAL INFORMATION
Initials:
Age:
Sex:
Ethnic Group:
Marital Status:
Occupation:
Current Employment Status:
Insurance Coverage:
Date of Admission:
Diagnosis:
Reason for seeking Medical Assistance or Hospitalization:
Allergies:
Client’s Health History:
Family Health History:

II. NURSING ASSESSMENT


A. Socio – cultural
 How does the client view the current illness?
 What are the beliefs regarding health/healing practices?
 Religious and/or spiritual beliefs/practices?
 What is the client’s beliefs about family (e.g. structure, roles, loss, participation in
care, and decision – making)?
 Any special dietary considerations or preferences?
 Any language or communication difficulties?

B. Development
 Identify client’s status as it relates to Erikson’s developmental phases (e.g. old
age), psychosocial stage (e.g. late adulthood) and developmental tasks (e.g.
letting go). Describe observation made.
C. Psychological
 What is the client’s emotional state (e.g. depressed, shy, and angry)?
 How does the client seem to be coping with illness? Is the client using any defence
mechanisms? Any maladaptive response noted? Any fear or anxiety noted (e.g.
crying or excessive complaining)?
 Does the client seem disinterested or detached? Is the client able to express fears?
What is client’s perception regarding threats to body image and separation from
support system?

D. Physiological
1. Cerebral and Peripheral Innervation
 Level of consciousness (degree of alertness); degree of orientation to time,
place, and person? If confused, describe specific behavioural responses:
memory, difficulty speaking or swallowing, or organizing sentences? Ability
to follow directions? Are grips equal in strength? Test for strength in lower
extremities and describe. Any tremors or shaking? Lack of coordination?
Any numbers or tingling? Convulsion movements? Response to sensation
and painful stimuli? Hyperesthesia? Any fainting? Signs of paralysis? Any
change in guilt?
 Eyes: describe color of iris, sclera, and conjunctiva. Any evidence of
inflammation? Any mucus drainage or encrustations? Size and shape of
pupils? PERRLA? Consensual response? EOM? Strabismus? Describe
any evidence of visual ability or difficulty. Any edema of lids? Ptosis?
 Ears: Describe any evidence of actual hearing ability or difficulty. Symmetry
of placement? Size? Any wax build up, drainage, or debris? Tinnitus?
Vertigo?
 Diagnostic Studies: compare client values with normal values and describe
significance (e.g. LP, EEG, x – rays, CT Scan, myelogram, etc.)

2. Integumentary
 Hair: Color? Length? Any evidence of loss? Vermin? Flakes? Eruptions on
scalp? Dull or shiny? Texture distribution? Debris? Oil or dry?
 Nails: Color? Opacities? Shape (e.g. spoon nails, clubbing, etc.) length?
Any debris? Any ridges or cracks? Degree of brittleness? Growth pattern?
 Skin: describe the actual color of the skin. Describe how it feels: warm,
cool, moist, dry? Any eruptions or scales? Rashes (describe, if present)
turgor? Elasticity (describe)? Scaling? Discolorations? Scars? If present,
describe the scars as well as the surrounding tissue (e.g. edema, redness,
etc.), even if it is healed. Describe all wounds: size (in cm) and shape,
location, or drainage. If the drainage is present, describe amount color,
odor, condition of surrounding tissue, etc. Is there a break in the integument
due to I.V.’s? If present, describe the status of the site (e.g. any redness,
swelling, drainage, tenderness, or heat). All descriptions must be clear,
complete, and detailed.

3. Oxygenation
 Respiratory rate rhythm, depth? Identify client’s normal range (high and
low). How do your findings compare? Shape of chest? Is chest expansion
symmetrical? If not describe. Any shortness of breath, dyspnea,
orthopnoea? Use of accessory muscle? Nasal flaring? Is client a mouth
breather, chest breather, or abdominal breather? Any cyanosis? If present,
describe. Any cough? If present, when, how, frequent, type: dry or
productive (quantity, color, clarity of secretions produced)? Hemoptysis?
Respiratory chest pain? If present, when, severity, etc. assess for anterior,
posterior and bilateral breath sounds: what do you hear … rales, rhonchi,
wheezing, or friction rubs? Which lobes(s)? Is it heard upon inspiration,
expiration, or both? Is client receiving oxygen therapy? If so, amount?
Type? Per what method?
 Diagnostic studies: client’s values. Normal values and significance (e. g. x-
rays, sputum C and S, ABG, CBC with differential, lung scan, etc.).
4. Circulation
 Indicate and describe characteristics of all pulses, including apical (rate,
rhythm, strength); describe status of the vessel wall; pulse rate? Give
client’s normal rate (high & low) and compare your findings. Pulse deficit?
Blood pressure? Give client’s normal BP range (high & low) and make
comparison is there JVD? What are the results of your check for Homan’s
sign? Orthostatic hypotension? Any edema of extremities? If present,
which extremity (ies); describe specifically. Any chest pain (when?
Severity? Radiation? Describe specifically.) Palpitations? Capillary Filling
Time (must be less than 3 seconds)?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. CVP, serum cholesterol, SGOT, SGPT, LDH,
CPK, cardiac cath, EKG, chest x-ray, etc.)

5. Hematological
 Any bleeding tendencies? Fatigue? Shortness of breath? Extreme
weakness? Skin color and turgor? Any palpable lymph nodes? Describe.
Transfusion required? If so, what type? Iron supplements required?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. bone marrow aspiration, RBC, WBC, platelet
count, HCT, HGB, coagulation time, serum iron, etc.).

6. Immunological
 Any allergies? If so, describe the allergen and response. Childhood
diseases? Immunity: Active, Passive, Acquired, Natural, or Artificial,
Tonsils removed? Any swollen or tender lymph nodes? Any
immunosuppressive? Chemotherapy treatments?
 Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. Sedimentation rate, WBC, lymphocyte count, C
& S, biopsies, etc.).

7. Digestive and Bowel Elimination


 Digestive assessment: mouth and oral cavity: give complete description of
tongue, lips, mucous membranes: coated, chapped, cracked, lesions,
fissures, color and status of gums? Any bleeding, pigmentation, or
malodour? Describe condition of teeth: color, structure, any missing, or
dentures? Any throat soreness or discomfort? Abdomen: what is the
appearance ... distended, protrusions? Where? Symmetrical? Any visible
peristalsis? Venous pattern on abdominal wall? Any tenderness? If
present, describe. How does it feel to touch: firm or soft? Can you palpate
any masses (where, describe)? Bowel sounds present? Where (describe)?
Bruits? Any complaints of indigestion, nausea, or vomiting?
 Nutritional Status: Client’s height and weight. What does the client look like
with reference to nutritional status? Weight loss or gain? Fatigue?
Irritability? Lesions or eruptions on skin or mucous membranes? Pallor?
Type of diet ordered? Percentage of meals consumed? Usual intake
pattern? Intake pattern since hospitalization? Food preferences? Any NGT
feedings or TPN solutions?
 Elimination: Usual bowel habits prior to and since hospitalization? Stools:
characteristics, amount, shape, color, consistency, and odor?
 Diagnostics Studies: compare client’s values with normal values and
describe significance (e.g. HVT, HGB, total protein level, albumin, guiac, x-
ryas, amylase, endoscopy, liver function lab tests, etc.).

8. Metabolism
 Client’s temperature? Any intolerance to heat or cold? Changes in voice or
vision? Any weight changes? Any change in hair growth and texture?
Polydipsia? Polyuria? Polyphagia? Poor wound healing? Any fatigue?
Weakness: drowsiness? Palpitations? Nervousness? Irritability?
Insomnia?
 Diagnostic Studies: compare client’s values with normal values and
describe significance (e.g. FBS, finger stick for glucose, serium TSH,
serum CA and Phos., (CT Scan, serum T3 and T4, radioactive iodine
uptake, etc.).
9. Urinary Elimination
 Is client receiving I.V. therapy with electrolytes? What type? Any evidence
of electrolyte imbalance? Monitor client’s output pattern during your clinical
time. What is the amount and frequency of client’s usual output pattern?
Compare 8 hour and 24 hour intake and output patterns and balance. Does
the client experience intermittency, frequency, dribbling, urgency, or
retention (is there any distention at the suprapubic area)? Any
incontinence? If present, describe the urine; any discharge? Burning on
urination? Describe the urine: color, odor, and clarity? Any haematuria?
 Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. serium electolytes, Co2, HCO3, UA, Bun,
creatinine. C & s, specific gravity, KUB, biopsies, IVP, etc.).
10. Reproductive
 Female: Describe appearance of vaginal mucus membranes and labia.
Complaints of pain or discomfort? Any discharge? If present, describe
color, consistency, odor, amount, associated, bleeding, spotting, pruritus
or irritation of the skin, etc. any malformations? Age of menarche? Last
normal menstrual period? Number of pregnancies? Number of live births
any abortions/ any breast tenderness or discharge?
 Male: development? Scars? Is client circumcised? Testes: relative size,
tenderness, or masses? Are both testicles descended? Any discharge? If
present, describe. Any malformations?
 Diagnostics Studies: Compare client’s values with normal values and
describe significance (e.g. biopsies, pap smear, mammography, urine
hormone levels, etc.).

11. Musculoskeletal
 Describe the overall muscle structure, build and tone. Any atrophy? If
present, where and to what degree? Any contractures? If so, which joints
specifically? Degree of ROM of all joints? If limited, then describe to what
degree (e.g. can extend elbow only 30 degrees). Ability to move self?
Gout? Smoothness of movement? Lordosis? Scoliosis? Kyphosis? Ant
fracture? If present, state location, presence of therapeutic devices (e.g.
traction, cast, etc.). How is movement affected? Ant swelling of joints,
redness, tenderness, or local heat?
 Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. x-rays, myelogram, arthogram, biopsy, serum
CA and Phos., etc.).
PLEASE EMPHASIZED ON THE IDENTIFIED SRESSORS WITHIN THE FOUR VARIABLES
AND THE SUBSYSTEMSWITHIN THE PHYSIOLOGICAL VARIABLE

I. VITAL INFORMATION
Initials: Age: Sex: Room #: Admission Date:

Medical Diagnosis:

Surgical Procedures: (This hospitalization):

Reason for seeking medical assistance or hospitalization:

Allergies:

Lines of resistance – Defence/ Patient health history:

Family health history:


II. NURSING ASSESSMENT
A. SOCIOCULTURAL VARIABLE/ INTERPERSONAL/ EXTRAPERSONAL STRESSOR
Occupation/ Current/Employment Status:
Economic Status:
Insurance Coverage:
Educational Attainment:
Residence: Does the patient live in a house (own/ rent), apartment, convalescent
hospital, etc.:

Marital Status:
Family Structure:
Patient’s Race & Ethnic Origin:
What are the patient’s cultural and ethnic beliefs regarding health/healing practices:

What are the patient’s religious/spiritual beliefs or practices related to or affecting


health:

Cultural response to hospitalization including privacy and personal space:

Values and beliefs about cultural family roles, participation in care, decision making
and separation from family:

Special cultural, or ethnic dietary considerations or preferences:

Primary language or communication difficulties:


Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the sociocultural variable. Remember to use NANDA terminology):

B. DEVELOPMENTAL VARIABLE
Expected developmental stage and tasks: (Erikson)

Identify patient’s present status as it relates to Erikson’s developmental phase


(Stages 1 – 8):

Behaviors observed indicating mastery or non-mastery of tasks:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the developmental variable. Remember to use NANDA terminology):

C. PSYCHOLOGICAL VARIABLE
How does the patient view this current illness:

Describe the patient’s emotional state and how they are dealing with the illness (e.g.,
depressed, shy, angry, sad, disinterest, insomnia, hypersomnia, etc.)

Cite the defense mechanisms the patient is using:


Describe the behavior that supports your assessment. Expressions or behaviors
indicating fear or anxiety such as crying, excessive complaining, etc.:

Are these behaviors indicative of danger to self or danger to others:

Patient’s perception of threats to body image:

Describe the patient’s support systems:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing assessment
of the psychological variable. Remember to use NANDA terminology):

D. PHYSIOLOGICAL VARIABLE (11 SUBSYSTEMS)


1. CEREBRAL AND PERIPHERAL INNERVATION
Level of consciousness (Degree of alertness):

Orientation to time, place, person & situation:

If confused describe specific behavioral responses:

Memory (recent):
Remote:

Difficulty speaking or organizing sentences:


Difficulty swallowing:
Response to directions:
Arm strength and equality:

Lower extremity strength and equality:


Tremors/shaking:
Numbness/tingling
Convulsions/seizures (Describe):

Response to sensation and painful stimuli:

Fainting/syncope:
Paralysis/weakness:
Abnormal gait:
EYES: Iris color:
Sclera color:
Conjunctiva color:
Evidence of inflammation, drainage or encrustation:

PERRLA:
Size of pupil:
Consensual response:
EOM:
Strabismus:
Describe evidence of visual difficulty:

Edema of lids:
Ptosis:
EARS: Describe any evidence of hearing difficulty:

Symmetry of placement:
Cerumen/drainage/debris:
Tinnitus:
Vertigo:
DRUGS:
LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture and
Sensitivity, Blood Work, etc.:

Gerontological Changes (If your patient is 65 or over please indicate the expected age
related changes in this subsystem. (Highlight the changes that you observed in your
patient all the way throughout your nursing care plan).

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing assessment
of the physiological variable. Remember to use NANDA terminology):

2. INTEGUMENTARY
HAIR: Color:
Length/distribution:
Evidence of loss:
Infestation/debris, flakes/scalp eruptions:
Dull/shiny:
Texture:
Oily/dry:
NAILS: Color:
Shape/length:
Debris:
Ridges/cracks:
Growth pattern:
SKIN: Color:
Moist/dry:
Warm/cool/hot:
Rashes/eruptions/scales (Describe):

Turgor/elasticity (describe):

Bruises/discoloration:

Scars (describe the scars as well as the surrounding tissue such as edema,
redness, etc. even if it is healed:

Describe all wound: Size and shape:


Drainage (amount, color, etc):
Condition of surrounding skin:

Describe pressure ulcers to stage, size and drainage:

Location:
Describe I.V. site (describe location, status, e.g., redness, swelling, drainage,
tenderness, heat or streaking):

DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:
Gerontological Changes (If your patient is 65 or over please indicate the expected
age related changes in this subsystem. (Highlight the changes that you observed
in your patient all the way throughout your nursing care plan).

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

3. OXYGENATION
Respiratory rate:
Rhythm:
Depth:
Shape of chest:
Expansion symmetrical (describe):

SOB/Dyspnea:
Orthopnea:
Nasal flaring:
Accessory muscle use:
Mouth/chest/abdominal breather:
Skin undertones: cyanosis (describe):

Cough:
When:
Frequency:
Type: Dry or Productive:
Sputum: description:
Chest pain (describe where, when and severity, etc.)

Assess anterior, posterior, lateral, inspiratory and expiratory bilateral breath


sounds:

Receiving oxygen: device and amount:

Pulse Ox reading:
DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:

Gerontological Changes (If your patient is 65 or over please indicate the expected
age related changes in this subsystem. (Highlight the changes that you observed
in your patient all the way throughout your nursing care plan).

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
4. CIRCULATION
RATE RHYTHM STRENGTH/SCALE CHARACTERISTICS
Apical
Femoral
Radial
Pedal
Pulse: High and Low: Normal:
BP: High and Low: Normal:
Edema (describe location, type and degree):
Extremity temperature change:
Chest pain: (describe when, where, severity, radiation, etc.)

Fatigue:
Palpitations:
Thromboguards/Ted hose:
CRT (<2 seconds or >2 seconds):
DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture and


Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
5. HEMATOLOGY
Bleeding tendencies:
Fatigue:
Dyspnea:
Petechiae:
Pallor, jaundice or cyanosis:
Weakness:
DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
6. IMMUNOLOGICAL
Allergies:
Describe the allergen/response:

Enlarged lymph nodes:


Hyperthermia:
DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

7. DIGESTIVE AND BOWEL ELIMINATION


Oral cavity description: (dry, cracked, bleeding, chapped, malodor, dentures):

Throat soreness or discomfort: (oral cavity):


Abdomen: flat/distended):
Protrusions:
Soft/firm/hard:
Visible peristalsis:
Abdominal wall venous pattern present:
Indigestion present:
Tenderness:
Masses:
Bowel sounds (describe type, heard):

Flatulence:
Nausea and/or vomitus (color, amount, odor, eructation):

Nutritional status: Height: Weight:


Weight loss: BMI:
Describe nutritional appearance: (use assessment guide): use Potter & Perry

Usual intake pattern:

Hospital intake pattern:

Food likes / dislikes:

Tube feedings (type of formula, method/route, residual amount):

Elimination: usual bowel pattern prior to and since hospitalization:

Stools characteristics (amount, color, consistency and odor):


DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

8. METABOLISM – ENDOCRINE
Temperature: high: low: normal:
Polydipsia, polyuria or polyphagia:
Fatigue:
Delayed wound healing:

DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:
Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

9. URINARY ELIMINATION
I.V. solutions:
Intake 8 hr.: 24 hr.:
Output 8 hr.: 24 hr.:
Fluid balance 8 hr.: 24 hr.:
Intermittency (urinary stream starts & stops):
Frequency (urinates how often?):
Dribbling (leakage):
Urgency:
Distention at the pubic arch:
Burning upon urination:
Urethral discharge:
Urine: color, odor, clarity:

DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:
Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

10. REPRODUCTION
FEMALE:
Breast pain/discomfort: Masses:
Nipple discharge (describe): Breast dimpling:

Age at Menarche: LMP:


Gravida/Para: Yearly mammogram:
Date of last mammogram: Genitalia abnormalities (e.g., lesions,
pruritus, spotting):

Vaginal discharge (describe):

MALE:
Circumcised: Scars:
Masses: Penis discharge (describe):

Any malformations:

Yearly PSA test? Date of last PSA test:


DRUGS:
LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture
and Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):

11. MUSCULOSKELETAL
Describe the overall muscle skeletal structure and muscle tone:

ROM of all joints active and/or passive:

If limited, describe the loss, such as, “can extend elbow 30 degrees”:

Contractures (where, degree):

Amputations:
Describe altered mobility and assistive devises:

Smoothness of movements:
Lordosis/scoliosis or kyphosis:
Fractures (type & location):

Treatment (devises, traction, CPM, casting, fixators, splints):

Joint swelling: (location, edema, redness, heat, itching, tenderness, etc):

DRUGS:

LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture


and Sensitivity, Blood Work, etc.:

Gerontological Changes:

Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
III. NURSING ANALYSIS
I. THEORETICAL KNOWLEDGE BASE --- In your own words, discuss the
knowledge base

Be specific and concise in your writing.

a. State the medical and surgical diagnosis as applicable.

b. Describe the function of the organ/system of defect in your own words.

c. Describe the pathophysiology of the illness at the cellular level, include


the signs and symptoms, etiology and risk factors.
d. Discuss how the illness effects the patient’s lifestyle while in the hospital
and at home.

e. Describe the textbook medical treatment for his illness

f. Describe the textbook nursing care management for a patient with this
illness

g. Compare and contrast your patient’s illness state with that of the
textbook.

2. STRESSORS. List all stressor under the appropriate categories.


a. INTRAPERSONAL

b. INTERPERSONAL
c. EXTRAPERSONAL

IV. NURSING PLAN


1. NURSING DIAGNOSIS – PRIORITIZED (8 in total), Use NANDA terminology.
1. Nursing Diagnosis

2. Nursing Diagnosis

3. Nursing Diagnosis

4. Nursing Diagnosis

5. Nursing Diagnosis

6. Nursing Diagnosis

7. Nursing Diagnosis

8. Nursing Diagnosis

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