Case

Patient Assessment Sheet (No-----) Total score = /

Division number:-----------------------------------
Submission date:--------------------------------------------------------------
Student's name:---------------------------------------------------------------Student's ID: ---------------------
Course title: ------------------------------------------------------------------Date of care:----------------------

I. History
A. Bio-demographic data
• Patient's initials:-----------------------------------------------------
• Department:----------------------------------------------------------
• Gender:----------------------------------------------------------------
• Age:---------------------------------------------------------------------
• Marital status:---------------------------------------------------------
• Level of education:---------------------------------------------------
• Occupation:------------------------------------------------------------
• Date of admission: ---------------------------------------------------
• Medical Diagnosis:----------------------------------------------------------------------------------------------
• Name of the current surgery:--------------------------------------------------------------------------------
• Date of the current surgery: ---------------------------------------------------------------------------------
• Number of the past surgery: ---------------------------------------------------------------------------------

Ø Reason for Hospitalization (Reason/s for seeking care)

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B. Current health status

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Code status: Full code (…) No code (…)
Allergies
Food:------------------------------------- Medication:---------------------------others:-------------------------------

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 C. General Appearance
• Facial expression: ---------------------------------------------------------------
• Grooming: ----------------------------------------------------------------
• Hygiene: -------------------------------------------------------------------

D. Vital signs (marks the parameters with their unit)

1. Temperature:
• Site:-------------------------------------Rate:------------------------------------
2. Pulse:
• Site:-----------------------Rate:------------------------Volume:---------------------Rhythm:----------------
3. Breathing
• Rate:---------------------Rhythm:-------------------Depth:-----------------------------------
4. Blood pressure
• Site:-----------------------Rate:----------------------------------
5. Oxygen saturation:
• Rate: --------------------------------
6. Pain:
Numerical Rating Scale (NRS). Patients are asked to choose a number that rates the level of pain, with 0
being no pain and the highest anchor, 10, indicating the worst pain.

• Severity:-----------------------------------------------
• Location:----------------------------------------------------------------------------------------------------
• Onset/duration:-------------------------------------------------------------------------------------------------------
• Radiation:---------------------------------------------------------------------------------------------------
• Aggravating factors:--------------------------------------------------------------------------------------
• Alleviating factors:---------------------------------------------------------------------------------------

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 Item Please circle If (yes) Specify
E. Medical history
Previous hospitalization No Yes Number: Reasons:

Comorbidities No Yes Number of comorbidities:

Name of comorbidity/s:

Previous surgery No Yes Number of previous surgery/s:

Name of previous surgery/s:

Immunization No Yes Type:

Previous blood transfusion No Yes Type: ____units’ number: ____Time:____ Reason:____
F. Family history
Cancer No Yes
Hypertension No Yes
Diabetes Mellitus No Yes
Kidney disease No Yes
Respiratory diseases No Yes
Heart disease No Yes
Liver disease No Yes
Other complain No Yes
I. Lifestyle/health patterns/habits
Medication:
- Prescribed No Yes
- Over counter No Yes
- Herbal supplements No Yes
Smoking:
- Smoker No Yes Type:_________ No of per day: ____
- Passive smoker No Yes No of years: ____
- Quitter No Yes
Alcohol intake: No Yes
Nutritional status: - Frequency: ------------------meals/day appetite:…………..
- Diet typeUsual daily diet:--------------------------------------
- Likes ----------------------------------------------------------------------------------
- Dislikes:--------------------------------------------------------------------------------
- Amount of fluid intake:--------------------L/day
- Height:------------------------------------------------
- Weight:-----------------------------------------------
- Body mass index:-----------------------------------
Elimination - Bowel frequency: ---------------------Characteristics-------------------------------
- Perceived constipation……………….
- Urinary frequency:---------------/day
- Urinary assistive devices: --------------------------------------------------------
- Color of urine:-----------------------------------------------------------------------
Sleep quality - Sleep hours: Naps ____ Night____
- Complain:-----------------------------------------------------------------------------
Level of activity: - Independent: ( )
- Partial dependent: ( ) Specify……..
- Dependent: ( ) Specify…………
Other concerns/complains:

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 II. Physical Examination
Item Please circle Specify
Head
Skull Normal Abnormal Symmetric Non symmetric
Face Normal Abnormal Symmetric Non symmetric
Scalp Intact Not intact Scratches:______ Lesions:____
Other complain No Yes
Eyes
Vision Normal Impaired Prosthesis:____ R/L Nearsighted Farsighted
Glasses
Sclera Color Normal Abnormal Yellow: ____
Pupils Normal Abnormal Equal Round Raxn To Light Accom
Convergence, Constricted Dilated
Other complain No Yes
Ears
Hearing Normal Impaired Prosthesis:____ R/L
Hearing aids: left ear right ear
Pain/Wax build up No Yes Left ear Right ear
Comprehension No Yes
Other complain No Yes
Nostrils
Drainage No Yes
Blockages No Yes
Sense of Smell Normal Abnormal
Congestion No Yes
Mucous Membranes Normal Abnormal Moist Pink Pale Pallor
Other complain No Yes
Throat/ 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:____ Dry:____
Oral Hygiene Normal Abnormal Good Poor
Swallowing Normal Abnormal Easy Difficult Painful
Excessive saliva
Lymph nodes Normal Abnormal Enlarged
Other complain No Yes
Neck
Jugular veins Flat Congested
Range of motion (ROM) Free Limited
Other complain No Yes
Integumentary system

Color Normal Abnormal Pink Jaundice Pallor Ashen Dusky Erythema

Cyanotic Aprop To Race
Hair Distribution Normal Abnormal Even Uneven
Moisture Normal Abnormal Wet Moist Dry Clammy
Temperature Normal Abnormal Hot Warm Cool Cold
Texture Normal Abnormal Smooth Rough
Turgor Normal Abnormal ____ Seconds
Vascularity Normal Abnormal High Normal Low

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Edema No Yes Type: ----------- Location: ________
Lesions/ Pressure Ulcer No Yes Location:_______ Shape:_______ Type: _____
Color:--------------------Stage:________
Cardiovascular system

Item Please circle Specify

A/P (S2 “dub”) Normal Abnormal Clearly Audible Muffled Murmur
Gallops
Erbs pointPt Clearly Audible Muffled Murmur
Equal Unequal Gallops
T/M (S1 “lub”) Clearly Audible Muffled Murmur
No Yes
Gallops
Apical rate Normal Abnormal
Apical Rhythm No Yes regular irregular
PMI located No Yes
Cap refill No Yes ---------Seconds Brisk Rapid Sluggish
Respiratory system

Breath Sounds Normal Abnormal Anterior clear wheezes crackles

Posterior clear wheezes crackles
Respiration Normal Abnormal rate: _____ even reg irreg labored
shallow deep
Chest Expansion Normal Abnormal symmetrical unsymmetrical
Cough No Yes Dry
Productive Color:--------------amount ------------
SOB No Yes Little Difficulty W/ Respirations
Oxygen supply No Yes on room air nasal cannula Mask---------------
Other complain No Yes Chest pain:____ Orthopnea: ____
Paroxysmal nocturnal dyspnea: _____ Dyspnea: __
(grade :……..)
Gastrointestinal system

Inspection Normal Abnormal Flat Round

Bowel Sounds Normal Abnormal x4 active hyperactive hypoactive faint
absent
Palpation Normal Abnormal soft hard firm tender non-tender
distended
Diet Normal Abnormal good average poor tube
Toleration of diet Normal Abnormal good average poor
Change in appetite No Yes Loss of appetite ? reason? Anorexia
Polyphagia Anorexia nervosa
Bulimia nervosa Cachexia Overeating
Recent weight change ≤3 No Yes Gain Loss
Months
NG/GT tube No Yes Intact Flushed Continuous Bolus Feeds
Last Bowel Movement Normal Abnormal When: How often:___________
Brown Yellow Black Tarry Green
Watery Soft Hard Formed
Diarrhea foul smelling
Urinary system
Urination Normal Abnormal Continent Incontinent Dysuria
Polyuria Anuria Oliguria Urgency
Hematuria Nocturia Diapers
Urinary assistive devices No Yes Urinary Catheterization
(internal or external) Urinary Condom

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Urine color Normal Abnormal Clear Cloudy Yellow Amber
Bloody Tea-Colored
Musculoskeletal system
ROM Normal Abnormal Upper extremities: full partial active
passive assistive
Strength Normal Abnormal Lower extremities: 1+ 2+ 3+ 4+
Upper extremities: 1+ 2+ 3+ 4+
Pulses Normal Abnormal Radial 1+ 2+ 3+ 4+
Dorsalis Pedis 1+ 2+ 3+ 4+
Gait Normal Abnormal Steady/Balanced Unsteady/Unbalanced
Limping Shuffled
Posture Normal Abnormal straight slumped
Ambulates Normal Abnormal w/o assistance w/ assistance crutches
walker cane wheelchair
Ability to perform ADLs No Yes
Edema No Yes Location: _____________
Nails color Normal Abnormal
Nails shape Normal Abnormal Clubbing: ____ Brittle: ____
Capillary refill Normal Abnormal < 3 sec, > 3 sec ____
Joints Free Limited Swelling: __ Deformed:__ Redness:__
Other complain Yes No Description: _______________
Neurological system
LOC Normal Abnormal Alert Lethargic Obtunded Stupor
Coma
Orientation Normal Abnormal x3 Person Place Time

Mood Normal Abnormal Happy Depressed Anxious Angry

Confused
Communication Normal Abnormal Clear/Effective Unclear/Ineffective
Partial
Motor Function Normal Abnormal Steady/Strong Unsteady/Weak Partial
Memory intact Yes No Recent Immediate memory problem:
Attention span problem:
Remote/short memory problem:
Glasgow Coma Scale
4 Spontaneous--open with blinking at baseline
3 Opens to verbal command, speech, or shout
Eye Opening Response
2 Opens to pain, not applied to face
1 None
5 Oriented
4 Confused conversation, able to answer questions
Verbal Response 3 Inappropriate responses, words discernible
2 Incomprehensible speech
1 None
6 Obeys commands for movement
5 Purposeful movement to painful stimulus
Motor Response 4 Withdraws from pain
3 Abnormal (spastic) flexion, decorticate posture
2 Abnormal Extension (rigid) response, decerebrate
posture
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 1 None
Total/ Comment
Wound Assessment

§ Location: use "X" to mark wound site on body diagrams

(__________________________)
§ Type: ____________________
Closed Clean
Open Clean contaminated
Contaminated
Infected
§ Skin surrounding wound: □ Intact □ Not intact
- If not intact, specify: __________________________

§ Open wound base: Epithelial

Granulation
Slough
Necrotic
§ Presence of wound drain or tube: Yes ____No ____
- If yes, specify: -

§ Type: Open system: _______ Closed system:_______

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

MORSE FALLS SCALE ASSESSMENT

Variables Numeric Values Score
1. History of falling No 0
_______
Yes 25
2. Secondary diagnosis No 0
_______
Yes 15
3. Ambulatory aid
None/bed rest/nurse assist 0
Crutches/cane/walker 15
Furniture 30 _______

4. IV or IV Access No 0
_______
Yes 20
5. Gait
Normal/bed rest/wheelchair 0
Weak 10
Impaired 20 _______

6. Mental status
Oriented to own ability 0
Overestimates or forgets limitations 15 _______

Morse Fall Scale Score = Total ______

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 § Test of cranial nerves

Nerve Nerve name Nature of the Nerve function Specify

number nerve (sensory, (normal or
motor, mix) abnormal)
Olfactory
I.
Optical
II.
Oculomotor
III.
Trochlear
IV.
Trigeminal
V.
Adbucens
VI.
Facial
VII.
Vestibulocochlear
VIII.
Glossopharyngeal
IX.
Vagus
X.
Accessory
XI.
Hypoglossal
XII.

III- Laboratory & Diagnostic findings:

a. Abnormal laboratory studies

Name of test Value (measurement unit) Interpretation/medical
normal value and patient’s value terminology of abnormal result
unit

b. Diagnostic studies
Name Date Result

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 IV- List of current medications (maximum 5 medications)

Name Dose Route Frequency Action Main Side Nursing Care of

effects main side effects
(mention at least 2)

V- List of patient's problems in priority (Nursing diagnosis and/or collaborative problems)

No Actual problems Potential problems

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Instructor’s feedback in points:

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Instructor’s signature---------------------------------------------Date -----------------------------------------

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 Nursing care plan (Number-------& Date-------------------)
Student's Name: …………………................................................ Student’s ID: …………………………….
Patient’s initial: ……………………………... Age: ……………. Gender: …………. Hospital No: ……….
Diagnosis: ……………………………............ Admission date: …………… Room No: .......... Bed No: …………..
Nursing diagnosis Goal & Interventions Rational Evaluation
outcomes
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Student's Signature……………………..
 Clinical Nursing Record + Nursing Notes
Student's Name: …………………................................................ Student’s ID: …………………………….
Patient’s initial: ……………………………... Age: ……………. Gender: ……… Hospital No:…………….
Diagnosis: ……………………………............ Admission date: …………… Room No: .......... Bed No: …………..

Vital Signs Medication

Date Fluid intake Fluid output
Pain & Observations & nursing interventions
Time T P R BL.P
Site Severity Kind Amount Kind Amount Treatment
-

Student's signature:-----------------------------------------Date-----------------------

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 Nursing Notes

Date/time Notes (D.A.R format)

D: Data; A: Action; R:response

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Clinical Rubrics