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VII.

NURSING
ASSESSMENT

A.)NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Jamisola, Shairalyn Date: June 23, 2014


Area: Out
Patient Department
Pulse: 92bpm
RR: 22cpm Temp: 38.00C
BP: 120/80mmHg
Weight:

B.) NURSING ASSESSMENT II


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

OXYGENATION
[ ]dyspnea
[ ]smoking history
none
[ ] cough
[ ]sputum
[ ]denied
CIRCULATION
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[ ] denied

Comments: no
verbal cues

Comments: no
subjective cues

OBJECTIVE
[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 3mm
[ ] speech difficulties
Reaction: Pupil Equally Round Reactive to Light
and Accommodation
Resp. [x]regular [ ]irregular
Describe: bronchovesicular breath sounds heard
over lungs; RR; 22cpm
R:symmetrical to Left lung upon expansion
L:symmetrical to Right lung upon expansion

Comments: no
subjective cues

Heart rhythm [X] regular [ ] irregular


Ankle Edema: non-pitting edema
Carotid Radial Dorsal Pedis Femoral
R
+2
+2
+1
+2
+2
L
+2
+2
+2
+2
+2
Comments: all pulses are palpable
*if applicable: not applicable

NUTRITION:
Diet: Diet As Tolerated
[ ] N [ ] V Character:
[ ] recent change in
Weight and appetite
[ ] swallowing difficulty
[ ]denied
ELIMINATION:
Usual bowel pattern
Once a day
[ ]constipation
Remedies:
None
Date of last BM
Not remembered
[ ] diarrhea character
None

[ ]dentures
Comments: no
subjective cues

[x] urinary frequency


>10 x per day
[ ]urgency
[ ]dysuria
[ ] hematuria
[ ] incontinence
[ ]polyuria
[ ] foley in place
[ ] denied

MGT. OF HEALTH & ILLNESS:


[ ] alcohol
[x]denied
(Amount, frequency): no subjective cues
[ ] SBE: none
Last Pap smear: none
LMP: none

Full
Upper [ ]
Lower [ ]

[X]none
partial
[ ]
[ ]

with patient
[ ]
[ ]

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

Briefly, describe the patients ability to follow


treatments (diet, meds, etc.) for chronic health
problems (if present).
N/A

SKIN INTEGRITY:
[x] Dry
[ ] Itching
[ ] other
[ ] denied
Comments: no
subjective cues
ACTIVITY/SAFETY:
[ ] convulsion
[ ] dizziness
[ ] limited motion
of joints
[x] ambulate
[x] bathe self
[ ] other
[ ] denied

[ ] LOC and Orientation: Patient is conscious and oriented to


time and space.

Comments: no
subjective cues

COMFORT/SLEEP/AWAKE:
[ ] pain (location) frequency
remedies)
Comments: no
[ ] nocturia
subjective cues
[ ] sleep difficulties
[ ] denied
COPING:
Occupation: Student
Members of household: members
Most supportive person: parents

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

[ ] Gait [ ] walker [ ] care [] others


[X] steady [ ] unsteady
Sensory 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,

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

Observed non-verbal behavior: none


Person (Phone Number): denied

A.)NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Jamisola, Shairalyn Date: June 25, 2014


Area:
Emergency Room
Pulse: 81bpm
RR: 21cpm Temp: 36.90C
BP: 90/70mmHg
Weight:

B.) NURSING ASSESSMENT II


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

OXYGENATION
[ ]dyspnea
[ ]smoking history
none
[ ] cough
[ ]sputum
[ ]denied
CIRCULATION
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[ ] denied

Comments: no
verbal cues

Comments: no
subjective cues

OBJECTIVE
[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 3mm
[ ] speech difficulties
Reaction: Pupil Equally Round Reactive to Light
and Accommodation
Resp. [x]regular [ ]irregular
Describe: bronchovesicular breath sounds heard
over lungs; RR; 21cpm
R:symmetrical to Left lung upon expansion
L:symmetrical to Right lung upon expansion

Comments: no
subjective cues

Heart rhythm [X] regular [ ] irregular


Ankle Edema: non-pitting edema
Carotid Radial Dorsal Pedis Femoral
R
+2
+2
+1
+2
+2
L
+2
+2
+2
+2
+2
Comments: all pulses are palpable
*if applicable: not applicable

NUTRITION:
Diet: Diet As Tolerated Except Dark Colored Foods
[X ] Nausea [ x] Vomiting
Character:
Comments:
[ ] recent change in
Nag suka ko
Weight and appetite
[ ] swallowing difficulty
[ ]denied
ELIMINATION:
Usual bowel pattern
Once a day
[ ]constipation
Remedies:
None
Date of last BM
July 24,2014
[ ] diarrhea character
None

[x] urinary frequency


>10 x per day
[ ]urgency
[ ]dysuria
[ ] hematuria
[ ] incontinence
[ ]polyuria
[ ] foley in place
[ ] denied

MGT. OF HEALTH & ILLNESS:


[ ] alcohol
[x]denied
(Amount, frequency): no subjective cues
[ ] SBE: none
Last Pap smear: none
LMP: none

[ ]dentures
Full
Upper [ ]
Lower [ ]

[X]none
partial
[ ]
[ ]

with patient
[ ]
[ ]

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

Briefly, describe the patients ability to follow


treatments (diet, meds, etc.) for chronic health
problems (if present).
N/A

SKIN INTEGRITY:
[x] Dry
[ ] Itching
[ ] other
[ ] denied
Comments: no
subjective cues
ACTIVITY/SAFETY:
[ ] convulsion
[ ] dizziness
[ ] limited motion
of joints
[x] ambulate
[x] bathe self
[ ] other
[ ] denied

[ ] LOC and Orientation: Patient is conscious and oriented to


time and space.

Comments: no
subjective cues

COMFORT/SLEEP/AWAKE:
[ x ] pain (abdominal area)
(location) frequency
Comments: no
remedies)
subjective cues
[ ] nocturia
[ ] sleep difficulties
[ ] denied
COPING:
Occupation: Student
Members of household: members
Most supportive person: parents

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

[ ] Gait [ ] walker [ ] care [] others


[X] steady [ ] unsteady
Sensory 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,

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

Observed non-verbal behavior: none


Person (Phone Number): denied