Patient Assessment Sheet

-Student's name: Njood Majed Khaled Omar - Student's ID: 442002563

-Course name: NUR-233 Adult (1) -Date of care:11/4/2022

* Bio-socio-demographic data

 Patient's initials:- O.M.A

 Department: Cardiac Ward 1 Nationality: Saudi ( ) Non-Saudi ( )
 Age: - 63 Y. O Religion: Muslim ( ) Christian ( )
 Gender:- □ Female
□ Male
 Marital status:-
□ Single □ Married □ Divorced □ Widow
 Level of education:-
□ Illiterate □ Primary □ Secondary □ University

 Occupation:- Unemployed
 Date of admission: - 7/4/2022
 Diagnosis:- Coronary artery disease
 Name of operation:- N/A
 Date of operation:- N/A
 Post-operative days:- N/A

1. Health history

 Reason for Hospitalization: Admitted for A typical chest pain

 Chief/present Complain: shortness of breath when exercise, angina, and nausea
o Onset: Sudden ( ) Gradual ( )
o Duration: A few weeks
o Aggravating factors: Work out
o Alleviating factors: Rest
o Associated manifestations: N/A

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 1. Health History
Item Please circle If (yes) Specify
 Past history
Previous hospitalization No Yes
Associated diseases No Yes Diabetes mellitus
Previous surgery No Yes
Allergies No Yes
Previous blood transfusion No Yes Type _Amount Time
 Family history
Cancer No Yes
Hypertension No Yes Patient's mother has hypertension
Diabetes Mellitus No Yes
Kidney disease No Yes
Asthma No Yes
Heart disease No Yes
Liver disease No Yes
Others No Yes
 Lifestyle/health patterns/habits
Medication: 1-Aspirin 2-Concor 3-Lasix 4-Diamicron 5-Isobide
- Prescribed No Yes
- Over counter No Yes 6-Zestril 7-Omedar 8- Crestor 9-Januvia

Smoking:
- Non-Smoker No Yes
- Smoker No Yes Type: No per day:
- Passive smoker No Yes No of years:
- Quitter No Yes
Alcohol intake: No Yes
Nutrition: - Frequency ( 2 meals/day)
- Likes and dislikes likes yogurt, laban and dislikes tomatoes
- Amount of fluid intake 2.5 L/day
Elimination - Bowel frequency 2 /day
- Urinary frequency 5-6 /day
Sleep - Sleep hours: Day 2 Night 4
Level of activity: - Independent ( )
- Partial independent ( ) Specify…….
- Dependent ( )
Others:

2. Physical examination
General appearance
* Consciousness: Conscious Altered Glasgow coma 15/15
* Patient's posture: Normal Scoliosis Kyphosis Lordosis _

* Grooming : Tidy Untidy * Gait: Normal Abnormal

* Weight: Normal Thin Obese * Hygiene:
Height: GoodWeight:Poor
171cm 76kg BMI: 26

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Vital signs
1. Temperature 36.7
2. Pulse: rate 62 rhythm irregular
3. Respiration: rate 19 rhythm Regular depth Deep
4. Blood pressure: value 106/55 site: Left arm
5. Pain: site Chest severity 8 on a scale from 1-10 radiation N/A increasing
factors Work out decreasing factors Rest

No pain Worst pain

Item Please circle If (yes) Specify

Amount and Normal Abnormal Brittle Alopecia
distribution of hair
Presence of lice No Yes
Hea

Presence of dandruff No Yes

d

Scalp Intact Not intact Scratches Lesions

Others No Yes

Color Healthy Unhealthy Pale Cyanotic Yellow

Eye
Vision Normal Impaired Prosthesis R/L
Color Normal Abnormal Yellow
Others No Yes

Ear
Hearing Normal Impaired Prosthesis R/L
Others No Yes

Nose
Patency Patent Nont-patent
Position of nasal Normal Abnormal
Fa
ce

septum
Others No Yes

Mouth
Lips Normal Abnormal Moist Dry Cracked
Mucus membrane Normal Abnormal Ulcers Patches Dry
Bleeding
Teeth Intact Lost Denture Dental caries
Odor Absent Present
Tongue Normal Abnormal Ulcers Coated Tongue Dry
Others No Yes

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 Item Please circle If (yes) Specify
Jugular veins Flat Congested
Neck

Range of motion Free Limited

(ROM)
Others No Yes
Inspection Barrel Kyphosis _ Funnel
- Shape of chest wall Normal Abnormal Pigeon
- Chest movements Equal Unequal
- Using of accessory
No Yes
muscles
- Others No Yes Oxygen therapy specify
(method: and liter_ )
Palpation
- Chest expansion Equal Unequal
- Tenderness No Yes
- Lumps No Yes
- Others No Yes
Che
st

Percussion Flatness Dullness Hyperresonant

- Percussion sound Resonant Abnormal Tympany Others
Auscultation
- Air entry Bil-equal diminished
- Breath sounds Normal Abnormal Wheezing Crackles Rhonchi

- Heart sound Normal Abnormal Murmurs Gallop Snaps

- Apical pulse Rate 96 Bpm Rhythm Regular
- Others No Yes Cough: dry ( ) wet ( )
Chest pain Orthopnea
Paroxysmal nocturnal dyspnea
Dyspnea (grade 2)
Inspection
Distension Ascites Hernia
- Shape Normal Abnormal
Ostomy
- Skin integrity Intact Abnormal Scars Rashes
Auscultation
- Bowel sounds Present Hypoactive Hyperactive_ Absent
Enema
Abdomen

Palpation Flat Abnormal Splenomegaly Hepatomegaly

- General palpation Lax Tenderness Mass _ Firm
Soft
- Feeding Oral Others NPO Anorexia Nausea
NGT _ Gastrostomy
Jejunostomy _ _ TPN
- Others No Yes Anorexia Pain Constipation
Diarrhea Vomiting Hematemesis
Melena Incontinence__

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5
 Item Please circle If (yes) Specify

Frequency /day Normal Abnormal Dysuria Polyuria _ Anuria

Urinary

Frequency Oliguria_ Urgency

System

Hematuria Incontinence
Urinary catheterization Nocturia
Skin color Normal Abnormal Cyanosis Pale Yellowish
Skin integrity Intact Abnormal Scars Lesion
Upper & Lower Extremities

Skin temp. Warm Abnormal Hot Cool Moist

Skin turgor Elastic Inelastic Dry
Sensation Normal Abnormal Parasthesia Numbness
Varicose veins No Yes Site
Edema No Yes Site Type _Degree
Nails color Normal Abnormal
Nails shape Normal Abnormal Clubbing Brittle
Capillary refill  3 sec Abnormal  3 sec
Joints Free Limited Swelling Deformed Redness
Others No Yes Amputation Site

Cervical Non Palpable

Lymph Nodes

palpable
Axillary Non Palpable
palpable
Femoral Non Palpable
palpable
Temporal Present Absent
Carotid Present Absent
Peripheral Pulse

Brachial Present Absent

Radial Present Absent
Femoral Present Absent
Popliteal Present Absent
Posterior Tibial Present Absent
Dorsalis pedis Present Absent
Presence of pressure Absent Present Location
Others

ulcers Stage

6
 Location: use "X" to mark wound site on body diagrams
(N/A)

Type: N/A
Closed Clean
Open Clean contaminated
Contaminated
Infected
Skin surrounding wound: □ Intact □ Not intact
Wound Assessment

- If not intact, specify: N/A

Open wound base: Epithelial

Granulation
Slough
Necrotic
 Presence of wound drain or YesNo
tube:
- If yes, specify:-
Type: Open system N/A Closed system N/A

Wound exudates/drainage
Type□ Bloody Serosanguineous □ Serous □
Amount□ None Small □ Moderate Purulent
□ Large
Odor□ None Foul

3. Laboratory & Diagnostic findings:

a. Abnormal laboratory studies
Name of test Value (unit) Name of test value
Potassium 5.85 mEq/L
Creatinine 144 mg/dL
CO2 14.70 mEq/L
Hemoglobin 12.3 g/dL
aPTT 42.1 s

b. Diagnostic studies
Name Date Result
ECG 7/4/2022 left ventricular hypertrophy, ST-T changes, and possible Q
waves
Cardiac catheterization 7/4/2022 Showed blocked vessels

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* List of current medications

Name Dose Route Frequency Name Dose Route Frequency

Aspirin 100 mg Oral Daily
Lipitor 40 mg Oral Nighty
Concor 2.5 mg Oral Daily
Plavix 75 mg Oral Daily
Clexane 40 mg Sub Q Q24h SCH
Nexium 20 mg Oral Daily
Novorapid 6 units Sub Q TID with
meals
Lantus 10 units Sub Q nightly
Zestril 5 mg Oral Daily

* List of patient's problems or nursing diagnoses (in priority):

Actual problems Potential problems (high risk)

1. Acute pain 1. Risk for decreased cardiac output

2. Anxiety 2. Risk for

3. 3.

4. 4.

5. 5.

6. 6.

7. 7.

8. 8.

9. 9.

10. 10.