VI. Nursing Assessment (System Review & Nsg.

Assessment II)

NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Patient D Date: July 5, 2009

Pulse: 85 bpm BP: 110/70 mmhg Temp: 36.2 C Height: 5’6’ Weight: 135lbs

EENT:

[ X] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened

[ ] Drainage [ ] Gums [ ] Hard of Hearing

[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion

[ ] Teeth [ ] No P,roblem

Assess Eyes, Ears Nose, and Throat for Abnormalities.

RESPIRATORY SYSTEM:

[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales

[ ] Cough [ ] Barrel Chest [ ] Bradypnea

[ ] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea

[ ] Orthopnea [ ] Labored [ ] Wheezing

[ ] Pain [ ] Cyanotic[X ] No Problem

Assess Resp. Rate, Rhythm, Depth, Pattern,

Breath Sounds, and Comfort.

CARDIO VASCULAR:

[ ] Arrhythmia [ ] Tachycardia [ X ] Numbness

[ ] Diminished Pulses [ ] Edema [ ] Fatigue [ ] Irregular

[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses

[ ] Pain [ ] No Problem

Assess Heart Sounds, Rate, Rhythm, Pulse,

Blood Pressure, Circulation, Fluid Retention, and Comfort.

GASTRO - INTESTINAL TRACT:

[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagea

[ ] Rigidly[ ] Pain [ X ] No Problem

Assess Abdomen, Bowel Habits, Swallowing,

Bowel Sounds, and Comfort.

GENITO - URINARY AND GYNE:

[ ] Pain [ ] Urine Color [ ] Vaginal Bleeding

[ ] Hematuria [ ] Discharge [ ] Nocturia [X] No Problem

Assess Urine Frequency, Control, Color,

Odor, Comfort, Gyne-Bleeding and Discharge.

NEURO:

[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures

[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors

[X] Confused [ ] Vision [ ] Grip [ ] No Problem

Assess Motor Function, Sensation, LOC, Strength,

Grip, Gait, Coordination, Orientation and Speech.

MUSCULOSKELETAL and SKIN:

[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae [ ] Hot

[ ] Drainage [ ] Prosthesis [ ] Swelling [ ] Lesion

[ ] Poor Turgor [ X ] Cool [ ] Deformity [ ] Wound

[ ] Rash [ ] Skin Color [ ] Flushed [ ] Atrophy [ ] Pain

[ ] Ecchymosis [ ] Diaphoretic [ ] Moist [ ] No Problem

Assess Mobility, Motion, Gait, Alignment,

Joint Function, Skin Color, Texture, Turgor, and Integrity.

2
- impaired vision, pt

wears eye glasses

- Skin is cold

- Urinary catheter

in place – decreased

urine output

- Fracture on the

distal phallanx 3rd

digit right foot

- IVF of D5LR 1L

@ 30gtts/min

- Numbness on the

lower left extremity

- vomited in small

amount

- Confused and

weak

Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate,
using (X).

NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Patient D Date: July 6, 2009

Pulse: 84bpm BP: 120/80 mmhg Temp: 37.1C Height: 5’8’’ Weight: 79 kg

EENT:

[X] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened

[ ] Drainage [ ] Gums [ ] Hard of Hearing

[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion

[ ] Teeth [ ] No P,roblem

Assess Eyes, Ears Nose, and Throat for Abnormalities.

RESPIRATORY SYSTEM:

[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales

[ ] Cough [ ] Barrel Chest [ ] Bradypnea

[ ] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea

[ ] Orthopnea [ ] Labored [ ] Wheezing

[ ] Pain [ ] Cyanotic[X ] No Problem

Assess Resp. Rate, Rhythm, Depth, Pattern,

Breath Sounds, and Comfort.

CARDIO VASCULAR:

[ ] Arrhythmia [ ] Tachycardia [ ] Numbness

[ ] Diminished Pulses [ ] Edema [ ] Fatigue [ ] Irregular

[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses

[ ] Pain [X] No Problem

Assess Heart Sounds, Rate, Rhythm, Pulse,

Blood Pressure, Circulation, Fluid Retention, and Comfort.

GASTRO - INTESTINAL TRACT:

[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagea

[ ] Rigidly[ ] Pain [X] No Problem

Assess Abdomen, Bowel Habits, Swallowing,

Bowel Sounds, and Comfort.

GENITO - URINARY AND GYNE:

[ ] Pain [ ] Urine Color [ ] Vaginal Bleeding

[ ] Hematuria [ ] Discharge [ ] Nocturia [ X ] No Problem

Assess Urine Frequency, Control, Color,

Odor, Comfort, Gyne-Bleeding and Discharge.

NEURO:

[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures

[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors

[ ] Confused [ ] Vision [ ] Grip [X] No Problem

Assess Motor Function, Sensation, LOC, Strength,

Grip, Gait, Coordination, Orientation and Speech.

MUSCULOSKELETAL and SKIN:

[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae [ ] Hot

[ ] Drainage [ ] Prosthesis [ ] Swelling [ ] Lesion

[ ] Poor Turgor [ X ] Cool [ ] Deformity [ ] Wound

[ ] Rash [ ] Skin Color [ ] Flushed [ ] Atrophy [ ] Pain

[ ] Ecchymosis [ ] Diaphoretic [ ] Moist [ ] No Problem

Assess Mobility, Motion, Gait, Alignment,

Joint Function, Skin Color, Texture, Turgor, and Integrity.

- Skin still cool

Pain

- IVF of D5LR 1L

@ 30 gtts/min

Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate,
using (X).

NUSING ASSESSMENT 2

SUBJECTIVE OBJECTIVE

COMMUNICATION
[ ] hearing loss

[X] visual changes

[ ]denied

[X] glasses [ ]languages

[ ] contact lens [ ] hearing aide

RL

Pupil size: 2-3 mm 2-3 mm

Reaction: Pupil equally round reactive to light and

accommodation

OXYGENATION:

[ ]dyspnea

[ ]smoking history

None

[ ] cough

[ ]sputum

[ ]denied

Resp. [X]regular [ ]irregular

Describe: difficulty in breathing with crackles

sound

R: symmetrical to the left side

L: symmetrical to the right side

CIRCULATION

[ ]chest pain

[ ] leg pain

[X] numbness of extremities

[ ] denied

Heart rhythm [X] regular [ ] irregular

Carotid Radial Dorsal pedis femoral

R: 83 84 86 +

L: 80 83 84 +

Comments: Pulses are palpable and heart rhythm

is regular.

*if applicable

NUTRITION:

Diet: Diet as tolerated

[ ] N [X] V

Character

[ ] recent change in weight

and appetite

[ ] swallowing difficulty

[ ]denied

[ ]dentures [x]none

Full partial with patient

Upper [] [ ] [ ]

Lower [] [ ] [ ]

ELIMINATION

Usual bowel pattern urinary frequency

Once a day 2-3 times a day

[ ]constipation [ ]urgency

Remedies: NA [ ]dysuria
Date of last BM [ ] hematuria

July 5, 2009 [ ] incontinence

[ ] diarrhea [ ] polyuria

Character: [X] foly in place

Brown colored stool

Bowel sounds: Audible bowel sounds – gargling

sound

Abdominal Distention

Present [ ] yes [ ] No

Urine (color, consistency, odor)

yellowish color .

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [X]denied

none

Briefly, describe the patient’s ability to follow

treatments (diet, meds, etc.) for chronic health

problems (if present).

The patient was able to follow strict

Comments: “Naa koy daot sa

akong mata, sukad pa grade 6

ga-suot nako ug eye glass.”

Comments: “Wala man ko

galisod ug ginhawa, wala pa

pud ko gapanigarilyo.”
Comments: “Murag

giputlan kog tiil, dili

nako kayo mabati-an

akong tiil-kadtong

bag-o gi-operahan.”

Comments: “Wala

man na-usab ako

timbang. Wa pud ko

ga-lisod ug tulon.”

[ ] SBE last Pap smear: NA

LMP: NA

compliance to the prescribed medication.

SKIN INTEGRITY:

[ ] dry

[ ] itching

[X]other

[ ] denied

[ ] dry [X]cold [ ] pale

[ ] flushed [ ]warm [ ]moist [ ]cyanotic

*rashes, ulcers, decubitus (describe size, location,

drainage) : No rashes and ulcers noted

ACTIVITY/SAFETY:

[ ] convulsion

[ ] dizziness

[x] limited motion of joints

Limitation in ability to

[X] ambulate

[X] bathe self

[ ] other

[ ] denied

[] LOC and Orientation: the client conscious and

oriented to time, place and person

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

[x] steady [ ] unsteady

[ ]Sensory and motor losses in face or extremities

No problems observed in the patients sensory

and motor function

[ ] ROM limitations: The patient is on complete

bed rest at the moment but he could perform

ROM exercises of the shoulders and hands

COMFORT/SLEEP/AWAKE:

[ x] pain (location,

frequency,

remedies)

[ ] nocturia

[x ] sleep difficulties

[ ] denied

[x ] facial grimace

[x ] guarding

[ x] other signs of pain moaning

[ ] side rail release form signed (60 + years)

NONE

COPING:

Occupation: NA

Members of household: 5 members

Most supportive person: mother

None observable behavior: patient able to

maintain eye to contact during assessment

Comments: “man akong

panit, tug-naw lang siya

kay tungod sa aircon”

Comments: “Dili

pajud ko ka-lakaw,

dili pa pud ko kaligo

nga ako ra

karon”

Comments: “ galisod ko ug

tulog, kai ga ngot-ngot man sa

kasakit akong tiil”