PATIENT PROFILE AND ASSESSMENT

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PATIENT PROFILE AND ASSESSMENT

PATIENT PROFILE AND ASSESSMENT

 

Student Name: ________________________________

 

Date: _____________________

 

  1. PATIENT PROFILE: (subjective data)

 

Patient Name (initials):_______       Date of Birth: _____________   Birthplace: _______________

 

Occupation: ________________________________   Highest grade of formal education: _________

Age: ______      Sex: ______             Race: _______________        Marital Status: _______________

 

Statement of Present Problem and Duration:

(Reason for seeking medical attention & when problem started)

 

ORDER A PLAGIARISM FREE PAPER NOW

 

 

 

 

  1. PATIENT: (Use the words in italic as a prompt for system specific illness/disease, previous hospitalizations that the student should inquire about. State what, when, and outcome. Do not leave any section blank. If no problems, state none or patient denies problems.) PATIENT PROFILE AND ASSESSMENT

 

 

Neurological: (headaches, migraines, weakness, ataxia, tics, tremors, seizures, vertigo, syncope, diminished sense of smell, touch, sensation, taste, numbness, tingling, head injury, LOC) 

 

 

 

Psychological: (depression, anxiety, eating disorder, schizophrenia, bipolar disorder)

 

 

 

Integumentary: (eczema, seborrhea, alopecia, skin cancer, hives, dryness)

 

 

 

Eyes: (glaucoma, cataract, vision problems, wears corrective lens)

 

 

Ears/Nose/Throat & Neck: (difficulty hearing, use of hearing aid, dental caries, bleeding gums, sinus problems, nose bleeds)

 

 

 

Respiratory: (COPD, emphysema, asthma, bronchitis, sarcoidosis, pneumonia, tuberculosis,  shortness of breath, cough)

 

Cardiovascular: (heart problems, hypertension, chest pain, palpitations, myocardial infarction, coronary artery disease, valvular disorder, atherosclerosis, thrombophlebitis, varicose veins, edema)

 

 

 

Gastrointestinal: (indigestion, ulcer, gastric reflex disease, dysphagia, gallbladder disease, pancreatitis, bowel disorders, hemorrhoids, constipation, diarrhea, incontinence, meal pattern, special needs, cultural restrictions, appetite)

 

 

 

Urinary: (kidney disease, incontinence, kidney stones, nocturia, hematuria, urgency, retention, dialysis, end stage renal disease)

 

 

 

Musculoskeletal: (muscle weakness, decreased range of motion/mobility, joint pain/stiffness/swelling, leg cramps, back pain, history of trauma, arthritis)

 

 

 

Male Reproductive: (testicular mass/cancer, erectile dysfunction, impotence, undescended testicle, prostate disease/cancer, dysuria)

 

 

 

Female Reproductive: (labial/vulvular pain/swelling, painful intercourse, uterine/ovarian problems, PID, dysmenorrhea, irregular menses, menopause, breast disease)

 

 

 

Endocrine: (diabetes, thyroid disease, goiter)

 

 

Lymph Nodes: (lymphoma, Hodgkin’s disease)

 

 

 

Hematological: (leukemia, anemia, hemophilia, bruising, blood transfusions~when and why)

 

 

 

Immunological: (frequent infections, diminished immune status, human immunity virus (HIV) infection)

 

 

 

Surgical History: (what for, when, any complications or adverse reaction to anesthesia)

 

 

 

Current Medications: (use attached medication list form)

Prescription:

Over-the-counter (OTC):

Herbals:

      Vitamins

 

Allergies:

Drugs:

      Food:

      Environment:

 

Immunization status: (tetanus, diphtheria, pneumonia, influenza)

 

 

 

Disabilities/Handicaps/Impairments:

 

 

 

Functional abilities related to: (I = Independent; P = Partial assist; C = Complete)

Identify ability to perform:

  • Bathing
  • Dressing
  • Toileting
  • Mobility
  • Eating
  • Bowel & bladder function

 

  1. FAMILY: (any serious, chronic or recurring illness or disease among immediate family members:

      1st generation = parent, child, sibling, or 2nd generation= grandparent, aunt, uncle)

 

 

 

 

III. HUMAN DIMENSIONS:

 

  1. Social:

 

Alcohol use:

 

Tobacco use:

 

Illicit drug use:

 

Caffeine consumption:

 

Work environment, past & present: (outdoor, office, healthcare, industrial, chemical exposure, heavy equipment)

 

 

Home Environment:

 

Psychosocial: (lives alone, roommate, family)

 

 

Physical: (single family home, apartment, nursing home, is there adequate space & privacy)

 

 

Support systems: (Interpersonal relationships/communication with others)

 

 

Characteristic Patterns of Daily Living: (usual daily routine)

 

 

 

  1. Spiritual:

 

Life Values: (what is important in life):

 

 

 

Advance Directives / End of life Issues (patient’s feelings and beliefs about heroic measures to     prolong life, life support through artificial means, and/or organ donation)

 

 

  1. Cultural:

 

Perception of health & illness: (what is seen as a state of being healthy, to what degree must health be altered for one to be considered ill)

 

 

 

 

Beliefs about illness: (curse, punishment, need for medications, blood product)

 

 

 

Reliance on folk medicine or home remedies: (Are such measures routinely used in lieu of conventional healthcare, what are some common practices if any)

 

 

 

 

 

 

Communication:

 

First Language:  English_____ Other (name) ______________________________

 

If English is not 1st language, is the patient able to express him/herself? _________

 

 

  1. Emotional:

 

Recent experience and effects of significant loss (death, divorce, relocation)

 

 

Coping (strategies used and effectiveness)

 

 

Patient’s presentation: (sad, angry, anxious, flat, apathetic, optimistic, happy, etc.)

 

 

 

  1. Prevention and Health Maintenance Activities:

 

Sleep pattern: (how many hours/24hour period, feel rested afterward, use of sleep aids)

 

 

Nutrition: (daily consumption of fruits, vegetables, whole grain foods, food storage and shopping practices)

 

 

Exercise: (type and frequency)

 

 

Stress Management: (what techniques are used and effectiveness)

 

 

Use of Safety Devices: (walker, cane, seat belts, motorcycle/bicycle helmet, sports equipment etc)

 

 

Health Check-ups: (self breast or self testicular exams, PSA, Pap smear, vision and dental exams)

 

 

  1. Developmental Stage:

 

Anticipated:

 

Actual:

 

 

 

 

 

  1. Learning Needs:

 

Education needs (diet, activity, and medications: ________________________________

 

Factors that might influence ability to learn: _____________________________________

 

Readiness and motivation to learn: _____________________________________________

 

Potential barriers to learning: __________________________________________________

 

 

Source and Reliability of Information: (patient, family/significant other, chart)

 

 

 

 

 

1V. DIAGNOSTIC TESTS and LABORATORY DATA

 

Diagnostic Test Patient Value Normal Range Interpretation
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

      

 

  1. Physical Examination: (objective data)

      General appearance:

 

Height:  ___________            Weight: _________lbs.           _________kg

 

Vital Signs: Temp: ______   Pulse: ______   Respirations: _______ Sa02_________

 

BP: (lying) _____________       (sitting)____________         (standing) ____________

 

Pain: On 0 – 10 scale = __________

Body movements/tremors:

 

Breath odor:    Alcohol_____ Fruity_____   Bad breath_____   Normal______

 

Fingernails:      Clean __   Dirty __     Filed__              Rough__     Evidence of biting__

 

Hygiene/grooming:  Clean__   Body odor__     Neat__         Disheveled__

 

Speech: Clear__   Unclear__      Loud__   Soft__    Spontaneous__  Halting ___

 

Neurological Status:

 

Glascow Coma Scale  
Best Eye Response Spontaneously 4
To speech 3
To pain 2
No response 1
Best Motor Response Obey verbal command 6
Localizes pain 5
Flexion-withdrawal 4
Flexion-abnormal * 3
Extension-abnormal ** 2
No response 1
Best Verbal Response

(record “T” if intubated or has a tracheostomy)

 Oriented x 3 *** 5
Conversation-confused 4
Speech-inappropriate 3
Sounds-incomprehensible 2
No response 1
  *Abnormal flexion-decorticate rigidity

** Abnormal extension- decerebrate rigidity

*** Appropriate conversation

 Score

Jarvis, C. (2000). Physical Examination and Health Assessment. W.B. Saunders Company: Philadelphia.

 

Pupils: Equal ___Unequal ___ Reaction to Light:

Pupil size: ______________

1 2 3 4 5 6 7 8
— — — — — ˜ ˜ ˜

 

 

Movement of Extremities: Spontaneous ____            Painful Stimuli _____ None _____

Equal _____    Unequal ____   Purposeful _____   Non-purposeful _____

Cranial Nerve Assessment:  Smile: equal  unequal   Gag: present  absent

Cough: present  absent

Shoulder shrug: equal unequal   Hand grasp: strong equal unequal flaccid

 

 

Cardiovascular Status:

Heart sounds: S1S2 ____  S3 _____ S4 ___  Murmur: ____       JVD: ____ cm

Pulses: Apical ______    Radial _____ Brachial _____   Popliteal ______ Pedal ______

Pulse grading: 3+- full bounding   2+  normal  1+- weak, thready   0-absent   D-Doppler

Capillary Refill:  Normal (2 sec) _____ Slow (> 2 sec) _____ BP:_____ CVP: _____

Edema: Yes No  If yes: Non-pitting ____  Pitting:____ 1+ ___ 2+ ___ 3+ ___ 4+ ___ Location:______________________________

IV access (circle all that apply): Peripheral IV   PICC  Triple lumen catheter

port-a-cath  Quinton  AV fistula AV graft  Other(describe): ______________________

Location of access device(s): _______________________________________________

Intravenous Solution infusing ______________________________@ __________ml/hr

Respiratory Status: (Include oxygen administration)

Pulse Ox ______%

Oxygen Therapy (circle): None   Nasal Cannula  Venti-mask  Simple mask  100% non-rebreather mask

Breath Sounds: Present: R / L   Absent:  R / L

C Clear
CR Crackles
RH Rhonchi
W Wheeze

RUL:  ________         LUL: _______

RML: ________         LLL:  _______

RLL:  ________

Clears with suctioning: yes  no    Chest movement: Equal ___Unequal ____

Secretions:  Yes/ No   If Yes: Color ___________    Amount _______  Consistency __________

Chest Tube(s): Number________      Suction________     Gravity _______

Tracheostomy: Yes____   No ____

Gastrointestinal Status:

Abdomen: Soft ___   Flat ____ Obese ___   Firm ___   Distended ___   Round ___ Tender ___

Non-tender ___

Bowel Sounds:  Present ____ Hypoactive _____ Hyperactive ______ Absent ______

If bowel sound(s) absent identify which quadrant(s)______________________

Date of Last Bowel Movement _________________           Consistency ______________

Blood in stool ___ Diarrhea ____   N/V ______

Diet: Type _______________            Amt Consumed _________%    NPO _____

Nasogastric or Gastrostomy Tube: Type _________________   To Suction __________

Nasogastric or Gastrostomy Output:  Amount________       Color __________

Nasogastric or Gastrostomy feeding: Type, Amount, Freq. _______________________________

Genitourinary Status:

Self voiding ____   Incontinent _____   Indwelling Foley Catheter _____   Size____

Urine Color ___________      Clarity ________Sediment _________

Bladder Irrigation _____        Color: ___________ Clots ______

Intake and Output _______/_______

Musculoskeletal Status:

Pain ___    Swelling ___         Deformity ____     ROM:  Limited _____________     Full ____

Ambulation: self______   assist_____   assistive device______/type______________________

Integumentary Status:

Intact ____      Lesions ___     Warm ___       Cool ____       Dry ____         Diaphoretic _____

Turgor: Normal ____  Decreased ___

Edema: Absent ____    Present ____   Site __________________________ Degree __________

Color:  Normal ___     Pale ___    Cyanotic ___ Mottled ___            Jaundiced ___    Flushed ___

Mucus Membranes:   Dry ___    Moist ____

VII. Risk Assessments

  1. Fall (1 yes = slight fall risk, 2 = moderate fall risk, 3+ = high fall risk)

     (Fall precautions must be instituted for any patient with at least 2 risk factors)

Above age 65                                                              Y / N

Abnormal mental status                                                           Y / N

CNS Depressants                                                         Y / N

Needs Assistance with elimination                               Y / N

Protective Devices (restraints)                                      Y / N

 

 

Braden Pressure Ulcer Risk Assessment (Skin Breakdown)

Sensory Perception

 

 1. Completely Limited:

Unresponsive (does not moan, flinch or grasp) to painful stimuli due to diminished level of consciousness or sedation.  Or limited ability to feel pain over most of body surface.

 2. Very Limited:

 Responds only to painful stimuli.  Cannon communicate discomfort except by moaning or restlessness. Sensory impairment limits the ability to feel pain or discomfort over ½ of body.

 3. Slightly Limited:

Responds to verbal commands but cannot always communicate discomfort or need to be turned. Or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

 4. No Impairment:

Responds to verbal commands, has no sensory deficit which would limit ability to feel or voice pain or discomfort.

 Score
Moisture

 

 1. Constantly Moist:

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

 2. Very Moist:

Skin is often, but not always, moist. Linen must be changed at least once a shift.

 

 3. Occasionally Moist:

Skin is occasionally moist, requiring an extra linen change approximately once a day.

 4. Rarely Moist:

Skin is usually dry, linen only requires changing at routine intervals.

  
Activity

 

 1. Bedfast:

Confined to bed.

 

 2. Chairfast:

Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

 3. Walks Occasionally:

Walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

 4. Walks Frequently:

Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

  
Mobility

 

 1. Completely Immobile:

Does not make even slight changes in body or extremity position without assistance.

 

 2. Very Limited:

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

 3. Slightly Limited:

Makes frequent though slight changes in body or extremity position independently.

 4. No Limitations:

Makes major and frequent changes in position without assistance.

  
Nutrition

 

 1. Very Poor:

Never eats complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.  Or is NPO and/or maintained on clear liquids or IV’s for more than 5 days.

 2. Probably Inadequate:

Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day.  Occasionally will take a dietary supplement. Or receives less than optimum amount of liquid diet or tube feeding.

 3. Adequate:

Eats over half of most meals. Eats a total of 4 serving of protein products per day. Occasionally will refuse a meal, but will usually take a supplement if offered. Or is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

 4. Excellent:

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat or dairy protein products. Occasionally eats between meals. Does not require supplementation.

  
Friction and Shear

 

 1. Problem:

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible.  Frequently slides down in bed or chair, requiring repositioning with maximum assistance.  Spasticity, or agitation lead to almost constant friction.

 

 2. Potential Problem:

Moves feebly or requires minimum assistance.  During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices.  Maintains relatively good position in chair or bed most of the time but occasionally slides down.

 3. No Apparent Problem:

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

    

Note: Patients with a total score of 18 or less are considered to be at risk of developing pressure      Total Score = ulcers.

(19 – 23 = no risk. 15 – 18 = low risk, 10 – 12 = high risk, < 9 = very high risk)

Source: Perry and Potter page 1288-1289

 

Indicate on Anatomical diagram any amputations, presence of wound(s), bruises, skin tears, rashes, or other types of skin impairments.

 

 

 

 

 

 

  1. Discharge Planning Needs

 

 

 

 

 

 

 

 

  1. Prioritized List of Nursing Diagnoses (Based on Preceding Assessment Data) at least 3.

 

 

Prince George’s Community College

Department of Nursing

NUR 1020 – Foundations of Nursing Practice

Medication Sheet to Accompany Patient Profile and Assessment

 

Name & Classification Actions of the drug & Why is your patient receiving this drug Patient Dosage

&

Safe dose range

 Common Side Effects Nursing Implications
 

Generic:

 

Brand:

 

Functional

Classification:

 

 

 

 

 

 

Generic:

 

Brand:

 

Functional

Classification: