Revised 01/99; 09/99; 10/08; 01/2010

KSPN / NCKTC
CORE CURRICULUM

ACTIVITY AND EXERCISE ASSESSMENT

Client's Initials ___________ Rm___________ Student_____________________________

Presence of: YES NO Describe findings

Orthopnea

Dyspnea

Cough

Chest Pain

Numbness

Tingling

Fatique

Sputum

Use of Tabacco ________ Type ____________ Duration? ___________ Frequency/amount __________

Respiratory Rate ____________ Rhythem ______________ Depth ______________________

Lung Sounds - - Normal _____________ Abnormal _____________ Describe _____________________

Temperature _____________ Oral ________________ Axillary _____________ Rectal ______________

Right Left

B/P & Pulse Lying

B/P & Pulse Sitting
B/P & Pulse Standing

Equal Bilateral Regular

1
 Revised 01/99; 09/99; 10/08; 01/2010

Pulse Rate YES Yes NO Strength Strength Scale

NO

Temporal 0 Absent

Carotid 1+ Weak

Brachial 2+ Full

Radial 3+ Bounding

Femoral

Popliteal

Dorsalis Pedis

Posterior Tibialis

Apical

Presence of Edema Pitting Edema Nonpitting Edema

Yes NO Yes NO Remarks

Face
Hands
Fingers
Sacrum
Knees
Ankle
Foot

Other

ASSISTANCE NEEDED TO : YES NO

Turn self

2
 Revised 01/99; 09/99; 10/08; 01/2010

Sit

Stand

Transfer

Ambulate

ASSISSTIVE DEVICES

Prosthesis

Crutches

Cane

Walker

Braces

Wheelchair

Transfer Belt

Restraints
Lap buddy, bed/chair alarm, etc.
Hydraulic lift

Other
RESTRICTIVE DEVICES
Cast/Splint/Brace/Traction
Suction
Oxygen needs
Foley
Monitor

Gait ___________________________ Posture _____________________________

Describe Findings _____________________________________________________________________

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

3
 Revised 01/99; 09/99; 10/08; 01/2010

RANGE OF MOTION FULL LIMITED NONE REMARKS

Head

Shoulder

Elbow

Wrist

Fingers

Hips

Knees

Ankles

Toes

Prescribed Exercise and/or rehabilitation

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What are the activities of a routine day?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Significant findings from physician assessment.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Significant findings from lab/ x-ray/ procedures. Include date test completed.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Potential / Actual nursing diagnosis derived from this health care pattern assessment:
____________________________________________________________________________________

4
 Revised 01/99; 09/99; 10/08; 01/2010

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How does this health care pattern and nursing diagnosis relate to the primary diagnosis of this client?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________