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Nursing Assessment

Client Name:
Admission Date:
Date Of Birth:
Gender:
Male Female Other
Race:
Caucasian Hispanic African American Asian Other
Age Years
Height FT
INCH
Weight LBS
Breathalyzer
Vital signs BP:
P:
R:
T:
Allergies
DRUG: NKDA other
LATEX:
FOOD: NKA other
OTHER:
Chief complaint::
Does the client exhibit signs/symptoms of active TB? Yes No

If yes, initiate TB precautions (request client to wear a surgical mask, have client remain in admission area until transfer to local medical facility can be arranged for screening)

Tuberculosis Screening:
Persistent cough more than 2 week
Hemoptysis (coughing blood)
Chest pains
Fever
Night sweats
Night sweatsShortness of Breath
Fatigue with no relief
Rapid weight loss
Severe loss of appetite
Recently exposed to someone with TB
GENERAL APPEARANCE ( check at least one from each category )
Orientation to:
Person Place Time Event
Facial Expressions Good eye contact Sad Worried Hostile Poor eye contact Expressionless Other
Dress Neat & Clean Meticulous Disheveled Clothing/Hygiene Poor Eccentric Seductive
Motor Activity WNL Agitation Tense Increased Decreased Amount Tremors Tics Other
Speech Incoherent Rapid Loud Pressured Slurred Slow Soft Other
Attitudes & Behavior Cooperative Hostile Guarded Suspicious Irritable Other
Intellect WNL Clear Logical Other
Mood & Affect Stable Sad Fearful Anxious Depressed Flat Affect Angry Elevated Mood
Flow of Thought Blocking Circumstantial Loose of Association Flight of Ideas Tangential
Nutritional Screen
Food Allergies/Intolerance:
Yes No
List:
Do you have any of the following (To evaluate dietary needs)?
Diabetes Mellitus
Kidney Disease
Liver Disease
Cancer
Celiac Disease
Swallowing Difficulties
Chewing Difficulties
Tooth/Gum Problems
Chronic GI Complaints
Poor PO intake
Frequent Dehydration
Gastric Bypass/lap band
Active Eating Disorder
History Eating Disorder
Pregnancy
Have you had extreme loss of weight?
What is your current Diet?
Regular diet
Vegetarian Diet
Gluten Free
Lactose Intolerance
Other
How is your appetite?
Poor Fair Good
Do you have any religious or cultural food preference that we need to be concerned about? Yes No Other
Highest Weight
Lowest Weight
Weight Loss
Gain
Over what period of time:
History of Eating Disorder? Yes No When
Restricting
Bingeing
Wakes during the night to Binge
Purging (forced or at will)
Laxative or Enema use
Diet pills or diuretic use
Epicac syrup
Counts calories (average per day)
Quantity of fluid intake per day
Exercise pattern
Weighing pattern
Hx of tube feeding
Age of Eating disorder began
Yesterday and today's food intake
Alcohol & Drug History
DRUG OF CHOICE
Alcohol Opiates Methamphetamine Benzodiazepine Cannabis Cocaine Other
DRUG OF CHOICE ALCOHOL
beer
hard liquor
wine
First taste of alcohol
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age drinking regularly
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Last used (date/time)
Amount used :
pint
bottle
shot
cans
other
Frequency :
daily
binge drinker
other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE OPIATES
Heroin
pill
Fentanyl
First use of Opiates
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age regularly used
15-20 y/o
21-25 y/o
26-30 y/o
other
Last used (date/time)
Amount used :
1/2 gram
1 gram
line
other
Frequency :
daily
occasionally
other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE METHAMPHETAMINE
First use of Methamphetamine
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age regularly used
15-20 y/o
21-25 y/o
26-30 y/o
other
Amount used :
1/2 gram
1 gram
line
other
Last used (date/time)
Frequency :
daily
occasionally
other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE BENZODIAZEPINE
First used of benzodiazepine
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age regularly used
15-20 y/o
21-25 y/o
26-30 y/o
other
Amount used :
1/2 gram
1 gram
line
other
Last used (date/time
Frequency :
daily
occasionally
other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE CANNABIS
First used of Cannabis
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
First used of Cannabis
15-20 y/o
21-25 y/o
26-30 y/o
other
Amount used :
1/2 gram
1 gram
line
other
Last used (date/time)
Frequency :
daily
occasionally
Other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE COCAINE
First use of Cocaine
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age regularly used
15-20 y/o
21-25 y/o
] 26-30 y/o
other
Amount used :
1/2 gram
1 gram
line
other
Last used (date/time)
Frequency :
daily
occasionally
other
Duration :
1-3 years
4-6 years
7-9 years
other
DRUG OF CHOICE OTHER
First use of
10- 15 y/o
16-20 y/o
] 21-25 y/o
26-30 y/o
other
Age regularly used
15-20 y/o
21-25 y/o
26-30 y/o
other
Amount used :
1/2 gram
1 gram
line
other
Last used
Frequency :
daily
occasionally
Other
Duration :
1-3 years
4-6 years
7-9 years
other
Route of Administration
Withdrawal signs and symptoms:
nausea/ vomiting
tremors
sweating
diarrhea
other
body aches
Hallucinations
yawning
indigestion
Recent/Current medical diagnostic testing and/or hospitalization:
Date
Tests
Date
Tests

Family History of Drug /Alcohol use

Drug /Alcohol use Drugs Alcohol other
Father
Mother
Uncle
Siblings
Grandfather
Grandmother
Auntie
Siblings
Other
Family History of Mental Illness: Yes No
Anxiety
Depression
Bipolar
Schizophrenia
PTSD
GAD
Personality Disorder
Other
Family History of Medical Illness: Yes No
Hypertension
Diabetes
High Cholesterol
Congestive Heart Failure
Asthma
Stroke
Personality Disorder
Other
Body Systems Review (Please check boxes under each system being evaluated)
Skin
Intact
Bruises
Pallor
Rash
Cold/ Clammy
Abrasions
Cyanosis
Warm/Dry
Jaundice
Other
Eyes
PERRLA
Constricted Pupils
Dilated Pupils
Jaundice
Visual Problems
ENT
No Current complaints
Hearing Problems
Other
Teeth and Gums
No Current complaints
Poor condition
Other
Neck
Supple
Enlarged Thyroid
Other
Breast
No current complaints
Other
Lungs/ Respiratory
Clear
Rales
SOB
Asthma
Hx. of COPD
Cough
Smoker
ppd yrs
Tuberculosis hx
Heart/ Cardiovascular
Rhythm regular
Rhythm irregular
Pacemaker
Hypertension
Chest Pain
other
Abdomen/GI
Soft
ender
Distended
Incontinent (bowel)
Nausea
Vomiting
Diarrhea
Constipation
other
GU
No current complaints
Bladder Change
Urinary Incontinence
Frequency
Urgency
Burning or Discomfort
Hematuria
Sexually Transmitted Diseases
other
GYN
N/A for males
LMP
Cycle Regular Irregular N/A
Menstrual Difficulties
Pregnancies (total/ live births )
Last Pap Smear
Upper Extremities
Full range of motion
Lower Extremities
Full range of motion
Edema
Unsteady Gait
Varicose Veins
other
other
Neurology
No current complaints
Headache
Blackouts
Seizures (when is the last episode)
Recent Head Injury
Weakness
Dizziness
Confusion
Hx Of head injuries ( when)
Endocrine
No current complaints
Diabetes since
Oral Medication Controlled
Diet Controlled
Weakness
Insulin Dependent
Hypoglycemia
Other
Sleep
Avg. hrs of sleep per night
2-4 hrs
4-6 hrs
other
Insomnia
Early awakening
Broken Sleep
Other
Anemia
Bleeding disorders
Cancer
other
Prosthesis/Devices Used
None
Glasses
Contact lenses
Right
Left

Full denture
Upper
Lower
Partial Denture
Other
BODY MARKING MAP

Indicate on the diagram all body marks by placement of legend/code on diagram indicating location of scars, bruises, tattoos etc.

  • Operative Scars
  • Trauma Scars
  • Burns
  • Birthmark
  • Lacerations
  • Acne
  • Tattoo
  • Edema
  • Rashes
  • Bruises and/or discolorations
  • Unusual body marks
  • Pressure Ulcer
  • Piercings
  • Needle tracks marks
  • Other




Line width :
Color :

Comments:
FALL RISK ASSESSMENT

A fall risk assessment is to be done on Clients at time of admission . A fall risk is defined as the state at which an individual is at risk for injury because of perpetual and /or psychological deficit, a lack of awareness, maturational age, or physical problems.

RISK FACTORS: If the total score is 15 or more, a nursing diagnosis of potential for injury is formulated on the treatment plan.

Low/Medium/High scoring for risk factors: 0 1 2 3 4 5

  • Substance intoxication
    0 1 2 3 4 5
  • Altered Mobility/ assistance to ambulate
    0 1 2 3 4 5
  • History of falls home/hospital
    0 1 2 3 4 5
  • Unsteady gait/ loss of limb
    0 1 2 3 4 5
  • Altered mental status
    0 1 2 3 4 5
  • Impaired Sensory (eyes/ears)
    0 1 2 3 4 5
  • Age greater than 65
    0 1 2 3 4 5
  • Pain
    0 1 2 3 4 5
  • History of seizure in past 6 months
    0 1 2 3 4 5
  • Fatigue
    0 1 2 3 4 5
TOTAL RISK SCORE :
PAIN ASSESSMENT
Do you have pain now ? Yes No
Do you have pain now ? Quality Aching Throbbing Dull Shooting Bursting Sharp Pressure
Describe
Chronic Pain : Onset
When did your pain start?
How often does it occur?
Where is the pain located?
What words would you use to describe your pain?
Current Pain level:
0
1-3
4-6
7-9
10
What makes your pain better?
medication resting stretching other
What makes your pain worse?
prolonged standing prolonged seating heavy lifting other
How does the pain affect physical and social function? (note decreased function, quality of life)
sleep appetite physical activity relationship with others emotions concentration accompanying symptoms other
What types of treatment have you tried to relieve your pain?
Chiropractor Physical Therapy Massage other
Were they and they effective? Yes No
SUMMARY
Staff Signature with credentials
Date
New-Brain-Center
Rhoncus aenean lacus consectetur neque facilisi pulvinar vitae interdum nam porttitor viverra
Office
  • 1141 SIBLEY ST, FOLSOM, CA
  • +(62)21 2002-2012
  • contact@centerforholisticmedicines.com
Office Hour
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  • 9:00 AM – 7:00 PM
  • Saturday
  • 9:00 AM – 5:00 PM
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