STUDENT NAME CLINICAL DATE
Section 1: Physical Assessment
DATE/TIME INITIAL ASSESSMENT 11/09/09 Date/Time* Possible Related Nursing
Explanation of Diagnoses
CHIEF COMPLAINT: Peripheral Vascular Disease Abnormal
PAST MEDICAL HISTORY: CHF, Peripheral Vascular disease, IDDM, Seizure disorder, Assessment Factors
anxiety disorder, Osteoarthritis, Malignant Neoplasm Prostate, Depressive disorder,
hyperlipidema, hypothyroidism, Hypokalemia
ALLERGIES:NKA
PAST SURGICAL HISTORY: Total Knee Replacement (rt knee)
Thin Obese Emaciated Well-developed Well-nourished No Acute Distress 11/09/09 1330 Latex Allergy Response
Height 5'8" Weight 271.3 BMI 41.2 Systolic BP was Latex Allergy Response,
Admitting Vital Signs BP: 154/71, PULSE: 84, PAIN: 0, RESP.: 18 , TEMP: 95.9 elevated. Risk for
Today’s Vital Signs BP: 128/60, PULSE: 80, PAIN: 0, RESP: 20, TEMP: 97 11/10/09 Stated that
BP was usually low in
the morning.
I. PHYSIOLOGIC ASSESSMENT
A. OXYGENATION
1. BREATHING Gordon’s Pattern of Activity and Exercise Airway Clearance, Ineffective
Respiratory Rate 20 Rhythm: Regular Irregular 11/10/09 0730 Aspiration, Risk for
Depth: Deep Shallow Stated had pneumonia Breathing Pattern, Ineffective
No distress Dyspneic Apneic sec. Gas Exchange, Impaired
a few weeks ago. No
Labored Accessory muscle use Tachypneic information found in the Infection, Risk for
Sudden Infant Death Syndrome,
medical record.
BREATH SOUNDS/LOCATION of FINDINGS Risk for
Cl -Clear Pleural Rub Suffocation, Risk for
Cr -Crackles Rh- Rhonci Ventilation, Impaired,
Wh –Wheezing R- Rales Spontaneous
D -Decreased Ventilatory Weaning
A -Absent Response, Dysfunctional
Oxygen Therapy:
RA FiO2 L / or % NC Mask Trach Other
O2 Saturation: N/A q hr Continuous pulse oximeter
Pulse Oximetry Readings (Identify on R.A. or O2): _; _;
Chest Config: Symmetrical Asymmetrical Flail
Cough: No cough Weak Strong Frequent Infrequent
Nonproductive Productive Description:
Color Odor Viscosity Incentive Spirometer
Shape of Chest: AP diameter 1:2, barrel, pectus excavatum,
(highlight or document) kyphotic; other
Drainage: Chest Tube/Pleuravac: R L Water seal only
Suction cm of water N/A
Medications R/T Breathing: Yes No Type
2. CIRCULATION Gordon’s Pattern of Activity and Exercise Cardiac Output, Decreased
Heart Rate (Radial Pulse) 80 Rhythm Irregular 11/09/09 1330 Fluid Balance, Readiness for
Heart Sounds: Describe chest area:barely audible/ No murmurs detected. At brachial Enhanced
2+Pitting edema RLE,
artery: Lub dub, pause, lub pause dub, lub dub Fluid Volume Deficit
and R/L ankles.
Neck Veins (45o angle): Flat Distended Fluid Volume Excess
11/10/09 0715
BP: R128/60 L 130/62 Apical Pulse:UTA D – Doppler Fluid Volume, Risk for Deficit
A – Absent Upon auscultation of
Arterial 1+ - Barely Palpable Fluid Volume, Risk for
DP 2+ - Weak the brachial artery, the Imbalanced
Pulses C B R F PT 3+ - Normal
4+ - Full Bounding heart sounds were Tissue Perfusion, Ineffective
irregular. (specify: renal, cerebral,
Right/
2+ Pitting edema cardiopulmonary,
Left 3+ 3+ 3+ 3+ A A
R/L LE 3+ pitting gastrointestinal, peripheral)
Capillary Refill: Brisk <3 sec. Prolonged >3 sec. sec.
edema both ankles.
Nail bed Color: Pink Pale Cyanotic
Chest Pain: No Yes Describe
Edema: None Generalized Non-pitting Pitting 1 + 2+ 3+ 4+
Other
Location L/R LE, (R/L ankles 3+) (R/L LE: 2+ )
WOSC Freshman Clinical Assessment Form -1-
,Pacemaker: N/A Permanent Type Has a history of
External Rate Ischemic heart
Location: disease, CHF,
Peripheral Vascular
Disease, and
hypertension. Bilateral
pedal pulses were
absent
2. CIRCULATION (Continued) Date/Time Related Nursing Diagnoses
Explanation of
Abnormal
Assessment Factors
Homan’s sign: Left: pos. neg. Right: pos. neg.
Calf redness/tenderness: Left: yes no Right: yes no
Anti-embolism stockings: N/A Remove/Replaced q shift
Sequential compression device: N/A Remove/Replaced q shift
Other
IV’s / INVASIVE LINE MONITORING
Type/Port ID** Solution Rate Dosage Location Site Code*
NONE
*SITE CODE: **ID INFUSION DEVICE:
C - Clear p - pump
S - Swelling pca+ - PCA
R - Redness g - gravity
I - Inflamed
DI - Dsg Dry & Intact
Medications R/T Circulation: Yes No Type Asprin 325mg QD, Lopressor
50mg PO q12h, Zaroxolyn 10mg po QD, Lasix 40mg po QD, ,Nitroglycerin 0.4mg
subling, Q 5minx3 PRN Chest pain
3. NEUROLOGICAL 11/10/09 0715 Confusion, Acute
Has a history of Confusion, Chronic
Level Of Consciousness:
seizures. Environmental Interpretation
Awake Alert Oriented x 4 (time, place, person, event)
Syndrome, Impaired
Restless Drowsy Sedated Confused
Infant Behavior, Disorganized
Glasgow Coma Scale: Infant Behavior, Readiness for
a) Best eye opening: 4 Spontaneously 3 To Speech 2 To Pain 1 None Enhanced Organized
b) Best verbal response: 5 Oriented 4 Confused Infant Behavior, Risk for
3 Inappropriate words 2 Incomprehensible sounds 1 None Disorganized
Intracranial, Decreased Adaptive
c) Best motor response: 6 Obeys commands 5 Localizes to pain
Capacity
4 Withdraws 3 Flexion (decorticate)
Memory, Impaired
2 Extension (decerebrate) 1 None
Thought Processes, Disturbed
Total Glasgow Coma Scale (Add a, b, c above)
PERRL Pinpoint Fixed
Dilated, but reactive to light Dilated, nonreactive
Unequal: R>L L>R Dolls eyes Other
Brain Stem Signs:N/A (+/-) cough gag corneal Babinski
Communication: Verbal Writes notes Mouths words
Nods head appropriately to yes/no questions
Medications R/T Neurological Condition: Yes No Type Topamax 100mg po QD ,
Lamictal 50mg po bid ,
4. NEUROVASCULAR 11/10/09 0715
WOSC Freshman Clinical Assessment Form -2-
, Extremities Examined: U/LE CSM q hr Partial loss of voluntary Dysreflexia, Autonomic
Traction/Cast: N/A Type movement of Dysreflexia, Risk for
Color: Pink Reddened Blue Blanched upper/lower extremities Autonomic
Temperature: Cool Warm Hot Rt side weakness Peripheral Neurovascular
Movement: Active Passive Limited LE cool to touch, shiny, Dysfunction, Risk for
Sensation: Numbness Tingling Pain waxy appearance; UE
Restraints: N/A Type CSM q hr warm. Venous Stasis
Restraint Protocol Instituted Remove/Replaced q shift noted. States feet and
legs are numb and
tingly.
B. NUTRITION Gordon’s Nutritional-Metabolic Pattern Date/Time Related Nursing Diagnoses
Explanation of
Abnormal
Assessment Factors
Abdomen: Soft Firm Hard Tender Distended cm. 11/10/09 0730 Breastfeeding, Effective
Breastfeeding, Ineffective
Bowel Sounds: Active Hyper Hypo Absent Abdomen is Breastfeeding, Interrupted
Flatus: Yes No distended. Dentition, Impaired
Diet: Type ADA/ LOW SODIUM NPO TPN Tube feeding ADA diet r/t IDDM, Failure to Thrive, Adult
Meal: Breakfast Lunch Dinner % taken 100% taken Fluid Volume, Deficit
and low sodium diet
Fluid Volume, Deficit, Risk for
Type gastric tube N/A Placement Verified r/t hypretension/ heart Infant Feeding Pattern,
Purpose: Feeding Decompression Other failure Ineffective
Formula: Type Rate cc’s q hrs N/A Pt is Obese, stated Nausea
Suction: N/A Intermittent Low continuous that he has gained Nutrition: Imbalanced, Risk for
Drainage: Describe More Than Body
alot of weight in the
Requirements
Mucous Membranes: Moist Dry Cracked Sores Patches past few months. Nutrition: Imbalanced, Less
Pink Dusky Other Than Body Requirements
Dentures: Full Upper Lower N/A Stated that he Nutrition: Imbalanced, More
Than Body Requirements
Diet toleration: Anorexia Nausea Vomiting sometimes sneaks
Nutrition, Readiness for Enhanced
Weight Loss: Amount Time Period N/A food that he is not Oral Mucous Membranes,
24o Intake UTA 24o Output UTA Balance: Positive Negative supposed to eat. Impaired
Blood Glucose Monitoring q 4 hrs Time/Result 1130 227 N/A Self-Care Deficit, Feeding
Swallowing, Impaired
Self-feed Assist-feed Swallowing precautions FSBS 227
Medications R/T Nutrition: Yes No Type Magnesium chloride 128mg po QD,
Potassium bicarbonate 120mEq liq po QID,Sitagliptin 50mg po QD, glyBuride 10mg QAM
0800, Novolog (sliding scale)
C. ELIMINATION Gordon’s Pattern of Elimination 11/10/09 0800 Constipation
Constipation, Perceived
1. BOWEL Prescribed several
Constipation, Risk for
Stool: Formed Loose Impacted Last BM 11/10/09 medications that have Diarrhea
Color: brown Regular Irregular constipation as a Incontinence, Bowel
possible side effect. Nausea
Outlet: Rectum Colostomy Ileostomy Rectal Tube Fistula Takes several
Output: Tube Drainage cc’s Describe: N/A medications to
Stoma: N/A Pink Edema Dusky prevent constipation.
Surrounding Skin: D/I Excoriated Other
Toileting: Self Assist History Laxative Use: No Yes
Medications R/T Bowel: Yes No Type Milk of Mag suspension 30 cc liq po QD
PRN, Dulcolax 1 suppository rectally QD PRN, Colace 200mg po bid, miralax 17gm po
bid,
2. URINARY 11/10/09 0700 Fluid Volume, Risk for
Imbalanced
GU Drainage: Voiding Straight Catheter q hrs Incontinent most of Infection, Risk for
Indwelling Foley 3-way cath (irrigation) the time, but tries to Incontinence, Functional
External cath Other use a urinal. States Incontinence, Reflex
Other: Bladder Training Catheter Care Hourly Urine Output that he has to “pee a Incontinence, Risk for Urge
Bladder Irrigation: Continuous Manual Solution: Incontinence, Stress
lot” at night. (nocturia)
Incontinence, Total
Urine: Clear Cloudy Sediment Odor: Faint Offensive Has a history of Incontinence, Urge
Color: Light Yellow Dark Yellow Orange Clots Hematuria malignant neoplasm Tissue Perfusion, Ineffective
Patterns: Incontinent Polyuria Nocturia Oliguria Urgency prostate. Urinary Elimination, Impaired
Dysuria Retention Anuria Other Urinary Elimination, Readiness
for Enhanced
Genitalia: No Anomalies Discharge Excoriation Other Urinary Retention
Medications R/T Bladder: Yes No Type Detrol LA 4mg po QD
D. ACTIVITY/REST Gordon’s Pattern of Activity and Rest/ Pattern of Sleep & Rest
WOSC Freshman Clinical Assessment Form -3-
