Integrity • Professionalism • Commitment • Competence • Openness •

Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

Name: _______________________________________________________ RLE Group/Section: _________ Hospital Area: _______________________

Clinical Instructor: _____________________________________________

INITIAL PATIENT ASSESSMENT

Admission Date: Room: Time:

___AM ___PM

How admitted: • Ambulatory € Wheelchair € Stretcher € Ambulance € Other

Accompanied by: € Family € Friend € Other

VITAL SIGNS ORIENTATION

Temperature: Height Call light/Bed control [ ] Visitation Rules [ ] Bed Locked [ ]

Pulse: Weight (Actual) lbs. Television [ ] Phone [ ]

Respiration: Educational Channels [ ] Bathroom/Emergency light [ ]

BP: Lights [ ] ID Band On [ ]

PERSONAL ESSENTIALS LIST/ TRANSFER INFORMATION

Valuables to safe [ ] No [ ] Yes (list on valuables envelope only) Date/Room Date/Room Date/Room Date/Room
Sent Home [ ]

Essentials at bedside? (check only those that apply)

Rings [ ] Plain yellow metal [ ] Yellow metal with stone

[ ] Plain white metal [ ] White metal with stone

Watch - Describe

Hearing Aid [ ] Left [ ] Right

[ ] Eyeglasses [ ] Contacts [ ] Left [ ] Right

 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

Dentures Full: • Upper • Lower • Partial: • Upper • Lower•

Other: (Wheelchair, prosthesis, cane, etc.)

Admission Sending RN Sending RN Sending RN

Receiving RN Receiving Receiving RN

RN

ALLERGIES

• No known allergies • Yes

Allergies: Type of Reaction:

HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN NURSING DIAGNOSIS

1. Informant: [ ] Patient [ ] Family Member [ ] Unable to obtain

2. Present Illness/Current/Reason for Hospitalization:

Health Maintenance Altered

Noncompliance (Specify

3. Date last admitted: Never admitted

4. Previous Hospitalization/Surgical Procedures:

Infection, Potential for

Injury, Potential for

5. Medical Diabetes ____ Respiratory Disease_______ Kidney Disease______ Mental Illness _________ Other (Specify)
History: Hypertension ____ Hepatitis _____ Thyroid Disease______ Arthritis ___________
Heart Disease _____ Vision Disorder _____ Neuro-Muscular Disorders ______ STD ___________
Tuberculosis _____ Seizure Disorder: Problems with Anesthesia Other:_______________________________________
 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

6. Medications: Including OTC Dugs/Treatment Used at Home

See Emergency Department Medication Review Sheet List Room Below if Patient not seen in Emergency Time Last Dose
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________

Insulin’s: ____________________________________________ ___________________________

Transdermal:

7. Do you take your medications as ordered? • Yes • No Why? ________________________________________________________________________________________________________________________________________________

8. Disposition of Medications: • Not Brought with Patient • Sent Home with Family • Sent to Pharmacy

9. Use of • Alcohol • Tobacco • Recreational Drugs • Alcohol • Tobacco • Recreational Drugs

How much? ________________________________________________ How long? _________________________________________________________

SYSTEM ASSESSMENT NURSING DIAGNOSIS

• Chest Pain Rhythm • Regular Radial • Palpable Dorsalis • Palpable Edema • Present
Cardio-
Vascular
• Orthopnea • Irregular Pulses: • Non-palpable Pedis: • Non-palpable • Pitting

• Hypertension Type : • Pounding • Other • Other • Non-pitting

• Pacemaker • Thready • Absent

• Apical Pulse • Weak

• Cough • Symmetrical • Labored • Clear all lobes

Respi
Chest Breath Breath
ratory
• Productive Appearance: • Asymmetrical Patterned: • Non- labored Sounds: • Equal & Bilateral

• Non-productive • Crackles

• Dyspnea • Rhonchi

• Orthopnea • Wheezes

**1. Mobility Status: • Ambulatory • Ambulatory with Assist • Bed rest • Transfer with assist • Walker • Activity Intolerance
Cardiopulmonary

2. Assistive Devices: • None • Cane • Wheelchair • Crutches • Prosthesis • Pillows # ________ • Airway Clearance Ineffective

• Other : _________________________________________________________________________________ • Breathing Pattern Ineffective

 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

3. Limitations: • None • Weakness • Fatigue • Other _______________________________________ • Decreased Cardiac Output

• Activity Intolerance, Potential

_______________________________________________________________________________________
4. Do you have enough energy for desired activity? • Yes • No Described: _______________________
• Gas Exchange Impaired
_______________________________________________________________________________________
5. Activities of daily living: I= Independent A= Assist D= Dependent • Home Maintenance
_____ Feeding _____ Bathing _____ Grooming Describe ________________________
_____ Toileting _____ Dressing _____ Other • Management, Impaired

• Physical Mobility, Impaired

• Self Care Deficit, specify:

____________________________
• Other (specify) _____________

• Cramping
Musculo-
**• Pain Muscle Strength: (S= Strong W= Weak N= None)
skeletal
• Joint Stiffness • Spasms Grips: • Right • Left

• Swelling • Tremors Pushes: • Right • Left

Pupil Size • PERL • Alert Oriented to: • Person

Neurological
**• Headache Pain Level of

• Motor Disturbances • Other Consciousness: • Stuporous • Place

• Seizures Right ____________ • Semi comatose • Time

• Numbness Left ____________ • Comatose • Event

• Tingling • Combative

• Anxious

• Confused

**1. Visual Impairment: • None • Wears eyeglasses 4. Communication: Language/ Barrier • Yes • No • Pain

• Contacts 5. Level of Education: Grade: __________________ • Pain Chronic

• Blind • Right • Left • Communication Impaired

2. Hearing Impairment: • None • Hard Hearing 6. Pain Discomfort: • Verbal

• Deaf _____ Right _____ Left Describe: ________________________________ • Knowledge Deficit ( Specify)

• Uses hearing aid

______________________________
_____ Right _____ Left A. Precipitating Factors:
3. Speech Impairment: Describe: ______________________________ • Injury Potential for

• None • Cannot express • Sensory/Perception, Altered (specify) _______________________

• Slurring • Cannot understand B. How is pain controlled? • Thought Processes, Altered

• Mute • Tracheostomy Describe: ________________________________ • Unilateral Neglect

• Stutters • Laryngectomy • Other (Specify) ________________

 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

• Normal Temperature: • Hot Describe: • Decubitus • Bruises

Integumentary

• Pale • Warm • Rashes • Scars

• Flushed • Cool • Wounds • Not visible

• Cyanotic Turgor : • Good • Lesion • Others

• Jaundice • Fair

• Other • Poor

• Skin Intact

• Yes • No • Body Temperature, Potential Altered

Nutritional / Metabolic
1. Special Diet

• Fluid Volume Deficit

Describe: ________________________________________________________________________________
2. Frequency of Meals: Describe: ______________________________________________________________
3. Recent Changes in Appetite/ Eating/ Patterns? • Yes • No • Swallowing Impaired
Describe: ________________________________________________________________________________ • Infection Potential For
__________________________________________________________________________________________
• Nutrition: Less than Body Requirements, Altered
4. Have you experienced • Indigestion • Vomiting • Difficulty Chewing • Choking with meals
• Nutrition: More than Body Requirements, Altered
Current/recent • Nausea • Sore Mouth • Difficulty Swallowing • Full Feeling In Throat
Describe: ________________________________________________________________________________ • Oral Mucous Membrane, Altered
5. Recent weight Loss/Gain? • Yes • No • Skin Integrity, Impaired
Describe: ________________________________________________________________________________
• Skin Integrity, Potential Impaired

• Other (specify) __________________

HEALTH PATTERN ASSESSMENT
Gastro Intestinal

General • Well Nourished Oral • Dry Bowel • Present • Ostomies

Appearance: • Malnourished Mucosa • Moist Sounds: • Absent • Gastrostomy

• Obese • Nasogastric

• Jejunostomy
 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

Patients at Risk to Develop Pressure Sores

Identify any patient at risk to develop pressure sores by assessing the seven clinical parameters and assigning a score. Patients with intact skin, but scoring 8 or greater, should have the Nursing Diagnosis “Potential Impairment of Skin Integrity.” Directions: Choose the
number which best describes the patient’s status total the seven numbers.

Clinical Condition Parameters Score Clinical Condition Parameters Score Clinical Condition Parameters Score
General Physical Condition (Health Problem) Mobility (extremities) Skin/Tissue Status
Good (minor) 0 Full active range 0 Good (well nourished skin intact) 0
Fair (major but stable) 1 Limited movement with Fair (poorly nourished skin intact) 1
Poor (Chronic serious but not assistance 2 Poor (skin not intact) 2
stable) 2 Move only with assistance 4
Immobile 6
Level of Consciousness (to commands) Incontinence (bowel and bladder) Nutrition (for age and size)
Alert (responds readily) 0 None 0 Good (eats/drinks adequately - ¾
Lethargic (slow to respond) 1 Occasional (less than 2x in 24 hours) 2 of meal) 0
Semi- comatose( respond only to verbal or Usually (more than 2x in 24 hours) 4 Fair (eats/drink inadequately at least ½ of
Painful stimuli) 2 No control 6 meal) 1
Comatose (no response to stimuli) 3 Poor (unable/refuses to eat/drink less than
½ meal) 2
Activity
Ambulant without assistance 0
Ambulant with assistance 2
Chair fast 4
Bed fast 6

Total

HEALTH PATTERNS ASSESSMENT NURSING DIAGNOSIS

GENITO- Description per _____ Nurse _____ Patient
URINARY

Urine Color: • Clear • Hematuria • Bladder distension • Suprapubic Catheter

• Dark • Cloudy • Foley Catheter • Urostomy

• Other • Dialysis Access

__________________
• Constipation
ELIMINATION Description per _____ Nurse _____ Patient

• Diarrhea
1. Bowel: • No Problems • Diarrhea • Pain • Blood in stool
• Incontinence, Bowel
• Constipation • Incontinence • Hemorrhoids • Other
Describe: ____________________________________________________________________________ • Incontinence, Functional
2. Bladder: • No Problems • Incontinence • Frequency • Burning • Nocturia • Incontinence, Total
 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

• Retention • Dribbling • Dysuria • Urgency • Other • Urinary Elimination, Altered

• Urinary Retention
Describe: ____________________________________________________________________________
3. Interventions: • None • Laxatives • Suppositories • Enemas • Other
• Other (specify) ________________________________
Describe: ____________________________________________________________________________

• Role Performance, Altered

REPRODUCTIVE

• Penile Discharge • Pain • Inguinal Mass • Penile Implant • Other

Male
• Sexual Dysfunction
• Tenderness • Scrotal Mass • Breast Lumps • STD (Sexually Transmitted • Sexuality Patterns, Altered
Diseases)
• Rape Trauma Syndrome
Female LMP ____________ Last Pap Smear : __________ Pain With: Pregnant: • Body Image Disturbance
• Itching • Breast Lumps • Menstruation • Yes
• Other ( Specify)
Para ____________

Gravida _________ • Abnormal Bleeding • PMS • Intercourse • No

• Contraceptive • Discharge • Other

• Lives with spouse • Lives Alone • Lives with Family • Lives with friends • Communication Impaired
ROLE
1. Home Environment:
RELATION
SHIP • Verbal
2. Who do you rely on for emotional support? • Spouse • Family • Friend • Self • Others • Family Processes, Altered
Describe: __________________________________________________________________________________
• Grieving, Anticipatory

3. How does your illness/hospitalization affect your family/significant others? • Parenting , Altered
Describe: __________________________________________________________________________________
• Social Interaction

• Social Isolation

• Violence, Potential for Self Directed

COPING/ 1. Have you had recent changes in your life (job, move, divorce, death, major surgeries, and recent abuse)?
• Yes • No Describe: ______________________________________________________________________
STRESS
Or directed towards other
• Role Performance, Altered
2. Do you feel you are dealing successfully with stresses associated with this change?
Describe: __________________________________________________________________________________
• Fear

• Other ( Specify) ________________

1. Sleep : • No problem • Difficulty falling asleep • Difficulty staying asleep • Does not feel rested after sleep • Sleep Pattern Disturbance
SLEEP /
REST
• Other ( Specify) ________________________________
Other: _____________________________________________________________________________________
2. What helps you sleep? ________________________________________________________________________
 Integrity • Professionalism • Commitment • Competence • Openness •
Teamwork • Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: [email protected] +63 (088) 858-3880 / +63 917-376-5105

• Anxiety
SELF PERCEP 1. What concerns you most about your illness/hospitalization?
TION Describe: __________________________________________________________________________________
2. Does your illness and/or hospitalization affect your sexuality/body image? • Yes • No • Fear

• Powerlessness

• Self- Esteem Disturbance

• Other (Specify) ________________

1. Is religion important in your life? • Yes • No • Religion/Faith : ___________________________________ • Spiritual Distress

VALUES
BELIEFS
2. Do you have special religious request during this hospitalization? • Yes • No • Notify Volunteer Services • Other (Specify) ________________________________
Describe: ________________________________________________________ for Clergy
SAFETY 1. All areas with ** should be considered FPP.
2. FPP should automatically be instituted for pts who have / are: A. Fallen Previously
B. Confused, disoriented or combative
C. Chemical or Physical Restraints Required