TRINITY VALLEY COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING
PATIENT ASSESSMENT
LEVEL III
Student Name: Luis Salmon Date: 9/13/2025 Time: 9:30 am
Patient Initials: CJ Age: 54 Gender: Female
Informant: ☒ Patient Other: Click or tap here to enter text.
Mode of access: ☐ Ambulatory ☒ WC ☐Stretcher Other: Click or tap here to enter text.
From: ☐Home ☐ER ☐Dr. Office Other: Transfer from another hospital
Part 1 Concept: Clinical Judgment: Assessment
Reason for Admission/Chief Complaint (Pt’s own words):
Patient states “I was transferred from another hospital because they did not have a general surgeon over there”. “I was scheduled for surgery to
remove gallbladder stones”. “I feel now much better than I did but it hurts when I have to pee”. “It feels like burning, it isn’t as bad as it was
yesterday”. “The pain medicine they’ve given me has helped, also my migraines are almost gone, and I can go to sleep”.
Patient also expresses concerns about CT scan finding. “Nobody has come to talked to me about what it was found on my CT Scan”.
Vital Signs
T O P Reg Oxygen R BP Ht Wt BMI Usual Weight
36.2C R Pulse Ox Device/LPM
Irreg Lying
97.2F A RA/Oxygen 173.3cm 80kg
Standing
T Does not 16 5’8 ft 176.37lbs 26.64kg/m2 64.4kg
Sitting
apply
96% Room Air
137/76
Allergies
Allergies Reaction Allergies Reaction Allergies Reaction
Does not apply Penicillin (G,V) Rash, breathing difficulties Ceftriaxone Rash
Latex? Y or N
Codeine Rash
Chronic conditions
Lung Problems: ☒Stomach Problems: ☒ Thyroid Problems: ☐ Neurological Problems: ☐ Heart Problems: ☒ Liver Problems☐ Vision Problems: ☐ Kidney
Problems: ☐ Arthritis: ☐ Diabetes: ☐ Chronic infection: ☐ Psychiatric/Cognitive ☒ Treatment: Antianxiety and Antipsychotic medication Cancer: (where/type) Click or
tap here to enter text.Treatment: Click or tap here to enter text.
Comments:
Patient with COPD, hypertension, colitis and anxiety. Patient is currently on treatment for chronic conditions, currently taking Metoprolol for
hypertension, PPIs for stomach problems and anxiolytics (Buspirone) and antipsychotics (Aripiprazole) for anxiety and depression, this last one
related to polysubstance abuse disorder.
Past Medical History, Hospitalizations, and Surgeries:
COPD, hypertension, tobacco use disorder, colitis, sinus tachycardia, calculus of gallbladder with acute cholecystitis, polysubstance abuse, anxiety.
Family history: (X all that applies) ☒Heart disease ☒ Hypertension ☒ Diabetes ☐Stroke ☐ Seizures ☐ Kidney disease ☐Liver disease
Comments Patient states that mother had diabetes and hypertension, and father had heart disease
Home Medication (include Dose Frequency Reason for taking Medications (include OTC) Dose Frequency Reason for taking
OTC) Brand and Generic Brand and Generic)
Herbs and Supplements Herbs and Supplements
pg. 1
, Acetaminophen 1000mg Twice Pain Metoprolol 500mg Once daily Hypertension
daily
Aspirin Once Migraines Buspirone (Buspar) 20mg Twice Anxiety Disorder
500mg daily daily
Biotin 30mcg Once Vitamins 300mg Once a Tobacco
daily Bupropion day cessation
20mg 3 times Acid reflux 10mg Once daily Major depression
Omeprazole daily Aripiprazole
Loperamide 4mg As When having
needed diarrhea
Lives alone: ☒ Yes ☐ No Lives with Click or tap here to enter text. Feels safe at home: ☒Yes ☐No Stairs at home: ☒Yes ☐No
Sleep pattern: 5-7hrs a day Spiritual Activities: Christian, but does not go to church every Sunday Ethnic Background: white/caucasian
Immunizations current? ☒ Yes ☐No Last Influenza: Last year Last Pneumonia: 03/2023 Last Tetanus toxoid: In adolescent years
Nicotine Use: ☐No ☒Yes How much? 2 to 3 cigarettes a day How Long? Since she was 10 years old Do you live in a smoking environment? ☒Yes ☐ No
Alcohol Use: ☒No ☐Yes How much? Does not apply How Long? Does not apply Last Drink: Does not apply
Social Drug Use: ☐ No ☒Yes Type? Amphetamines, marijuana Frequency: When feeling anxious, once a week or once every two weeks. Currently trying to quit.
Support Services: ☒ No ☐ Yes Type ☐HHC ☐ Hospice Other: Click or tap here to enter text.
Additional Help needed: ☒ No ☐Yes Support person: ☐Yes ☐No Name: Click or tap here to enter text.
Comments Patient with tobacco disorder, being a smoker since she was 10 years old. Patient states that she has cut down 2 to 3 cigarettes, as opposed
to a pack that she used to smoke. Patient also confirms substance abuse due to anxiety with multiple unsuccessful attempts to quit.
Impairment / Disabilities
Yes No Yes No Yes No
Impaired hearing Hearing Aid ☐R ☐L Walker
x x x
Impaired vision Glasses Crutches
x x
Can perform ADL? Contacts Wheelchair
x x x
Can read? Dentures ☐U ☐ L Cane
x x x
Can write? Partial Prosthesis
x x x
Other/Comments: Contact lenses by Home O2 Rate: Other/Comments: Temporary use of cane due to surgery
optometrist since x
2020
Nutrition
Special Diet: Does not apply Supplements: Patient denies taking supplements
Comments: Patient has regular diet
Safety
ID Band on ☒ Yes ☐ No Allergy Band on ☒ Yes ☐No ☐ No Allergies Call Bell in Reach ☒ Yes ☐No IV pump ☐Yes ☐ No
Skin Integrity Assessment Scale: 23 (if 17 or below, Skin Risk initiated)
Fall Risk Assessment Scale: 20 (if above 25, Fall Prevention initiated)
Comments: No safety risks present
Skin Risk Assessment Scale Score 23
Sensory Perception 1. Completely limited – 2. Very limited – response to painful 3. Slightly limited – response 4. No Impairment – able to
Ability to respond to pressure unresponsive to pain or limit’s stimuli or limits ability to feel pain over ½ of to verbal command but can’t
body, or paralysis present verbalize feelings and complaints
related discomfort ability to feel pain over most of always communicate
body
Moisture 1. Constantly moist – (i.e. 2. Very moist – extra linen change 3. Occasionally moist – linen 4. Usually dry – no extra linen
Skin exposed to moisture perspiration, urine) 1x per shift change 1x per day changes
pg. 2
ASSOCIATE DEGREE NURSING
PATIENT ASSESSMENT
LEVEL III
Student Name: Luis Salmon Date: 9/13/2025 Time: 9:30 am
Patient Initials: CJ Age: 54 Gender: Female
Informant: ☒ Patient Other: Click or tap here to enter text.
Mode of access: ☐ Ambulatory ☒ WC ☐Stretcher Other: Click or tap here to enter text.
From: ☐Home ☐ER ☐Dr. Office Other: Transfer from another hospital
Part 1 Concept: Clinical Judgment: Assessment
Reason for Admission/Chief Complaint (Pt’s own words):
Patient states “I was transferred from another hospital because they did not have a general surgeon over there”. “I was scheduled for surgery to
remove gallbladder stones”. “I feel now much better than I did but it hurts when I have to pee”. “It feels like burning, it isn’t as bad as it was
yesterday”. “The pain medicine they’ve given me has helped, also my migraines are almost gone, and I can go to sleep”.
Patient also expresses concerns about CT scan finding. “Nobody has come to talked to me about what it was found on my CT Scan”.
Vital Signs
T O P Reg Oxygen R BP Ht Wt BMI Usual Weight
36.2C R Pulse Ox Device/LPM
Irreg Lying
97.2F A RA/Oxygen 173.3cm 80kg
Standing
T Does not 16 5’8 ft 176.37lbs 26.64kg/m2 64.4kg
Sitting
apply
96% Room Air
137/76
Allergies
Allergies Reaction Allergies Reaction Allergies Reaction
Does not apply Penicillin (G,V) Rash, breathing difficulties Ceftriaxone Rash
Latex? Y or N
Codeine Rash
Chronic conditions
Lung Problems: ☒Stomach Problems: ☒ Thyroid Problems: ☐ Neurological Problems: ☐ Heart Problems: ☒ Liver Problems☐ Vision Problems: ☐ Kidney
Problems: ☐ Arthritis: ☐ Diabetes: ☐ Chronic infection: ☐ Psychiatric/Cognitive ☒ Treatment: Antianxiety and Antipsychotic medication Cancer: (where/type) Click or
tap here to enter text.Treatment: Click or tap here to enter text.
Comments:
Patient with COPD, hypertension, colitis and anxiety. Patient is currently on treatment for chronic conditions, currently taking Metoprolol for
hypertension, PPIs for stomach problems and anxiolytics (Buspirone) and antipsychotics (Aripiprazole) for anxiety and depression, this last one
related to polysubstance abuse disorder.
Past Medical History, Hospitalizations, and Surgeries:
COPD, hypertension, tobacco use disorder, colitis, sinus tachycardia, calculus of gallbladder with acute cholecystitis, polysubstance abuse, anxiety.
Family history: (X all that applies) ☒Heart disease ☒ Hypertension ☒ Diabetes ☐Stroke ☐ Seizures ☐ Kidney disease ☐Liver disease
Comments Patient states that mother had diabetes and hypertension, and father had heart disease
Home Medication (include Dose Frequency Reason for taking Medications (include OTC) Dose Frequency Reason for taking
OTC) Brand and Generic Brand and Generic)
Herbs and Supplements Herbs and Supplements
pg. 1
, Acetaminophen 1000mg Twice Pain Metoprolol 500mg Once daily Hypertension
daily
Aspirin Once Migraines Buspirone (Buspar) 20mg Twice Anxiety Disorder
500mg daily daily
Biotin 30mcg Once Vitamins 300mg Once a Tobacco
daily Bupropion day cessation
20mg 3 times Acid reflux 10mg Once daily Major depression
Omeprazole daily Aripiprazole
Loperamide 4mg As When having
needed diarrhea
Lives alone: ☒ Yes ☐ No Lives with Click or tap here to enter text. Feels safe at home: ☒Yes ☐No Stairs at home: ☒Yes ☐No
Sleep pattern: 5-7hrs a day Spiritual Activities: Christian, but does not go to church every Sunday Ethnic Background: white/caucasian
Immunizations current? ☒ Yes ☐No Last Influenza: Last year Last Pneumonia: 03/2023 Last Tetanus toxoid: In adolescent years
Nicotine Use: ☐No ☒Yes How much? 2 to 3 cigarettes a day How Long? Since she was 10 years old Do you live in a smoking environment? ☒Yes ☐ No
Alcohol Use: ☒No ☐Yes How much? Does not apply How Long? Does not apply Last Drink: Does not apply
Social Drug Use: ☐ No ☒Yes Type? Amphetamines, marijuana Frequency: When feeling anxious, once a week or once every two weeks. Currently trying to quit.
Support Services: ☒ No ☐ Yes Type ☐HHC ☐ Hospice Other: Click or tap here to enter text.
Additional Help needed: ☒ No ☐Yes Support person: ☐Yes ☐No Name: Click or tap here to enter text.
Comments Patient with tobacco disorder, being a smoker since she was 10 years old. Patient states that she has cut down 2 to 3 cigarettes, as opposed
to a pack that she used to smoke. Patient also confirms substance abuse due to anxiety with multiple unsuccessful attempts to quit.
Impairment / Disabilities
Yes No Yes No Yes No
Impaired hearing Hearing Aid ☐R ☐L Walker
x x x
Impaired vision Glasses Crutches
x x
Can perform ADL? Contacts Wheelchair
x x x
Can read? Dentures ☐U ☐ L Cane
x x x
Can write? Partial Prosthesis
x x x
Other/Comments: Contact lenses by Home O2 Rate: Other/Comments: Temporary use of cane due to surgery
optometrist since x
2020
Nutrition
Special Diet: Does not apply Supplements: Patient denies taking supplements
Comments: Patient has regular diet
Safety
ID Band on ☒ Yes ☐ No Allergy Band on ☒ Yes ☐No ☐ No Allergies Call Bell in Reach ☒ Yes ☐No IV pump ☐Yes ☐ No
Skin Integrity Assessment Scale: 23 (if 17 or below, Skin Risk initiated)
Fall Risk Assessment Scale: 20 (if above 25, Fall Prevention initiated)
Comments: No safety risks present
Skin Risk Assessment Scale Score 23
Sensory Perception 1. Completely limited – 2. Very limited – response to painful 3. Slightly limited – response 4. No Impairment – able to
Ability to respond to pressure unresponsive to pain or limit’s stimuli or limits ability to feel pain over ½ of to verbal command but can’t
body, or paralysis present verbalize feelings and complaints
related discomfort ability to feel pain over most of always communicate
body
Moisture 1. Constantly moist – (i.e. 2. Very moist – extra linen change 3. Occasionally moist – linen 4. Usually dry – no extra linen
Skin exposed to moisture perspiration, urine) 1x per shift change 1x per day changes
pg. 2
