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

Division number: B1
Submission date: 16/ may/ 2023
Student's name:----- Shahad Moteb Almotaire Student's ID: 443005476---------------------
Course title:Adult2 Date of care:--4/April --------------------

I. History
A. Bio-demographic data
• Patient's initials:-----M.A------------------------------------------------
• Department:--------B1--------------------------------------------------
• Gender:-----------------Male-----------------------------------------------
• Age:------------------45---------------------------------------------------
• Marital status:--------------married -------------------------------------------
• Level of education:-----------------bachelor ----------------------------------
• Occupation:------------------teacher ------------------------------------------
• Date of admission: ------------------30/3/2023---------------------------------
• Medical Diagnosis:------------------------stroke----------------------------------------------------------------------
• Name of the current surgery:------------------None --------------------------------------------------------------
• Date of the current surgery: ----------------------none-----------------------------------------------------------
• Number of the past surgery: ------------------------none---------------------------------------------------------

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

--------------------stroke , when the patient came he had dizziness+ unsteady gait +Right side weakness .

B. Current health status

The patient is stable , the dizziness gone , the gait is steady and the swilling decreased
Code status: Full code (…) No code ( )
Allergies
Food:----------None--------------------------- Medication:-------None --------------------others:--------------N/A-----------------
C. General Appearance
• Facial expression: smily
• Grooming: grooming good he have good and clean
• Hygiene: ------clean and net

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:-----------not sever------------------------------------
• Location:-----------------------head-----------------------------------------------------------------------------

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• Onset/duration:-------------this morning ------------------------------------------------------------------------------------------
• Radiation:----------------------------not -----------------------------------------------------------------------
• Aggravating factors:------------------waking up from sleep--------------------------------------------------------------------
• Alleviating factors:-----------------------none----------------------------------------------------------------

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:

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: cigarette No of per day: ____
- Passive smoker No Yes No of years: ____
- Quitter No Yes
Nutritional status: - Frequency: ------------------meals/day appetite:…………..
- Diet type:----low sugar
- Likes: Saudi food -----------------------------------------------------------------
- Dislikes:--------none -------------------------------------------------------------
- Amount of fluid intake:----0.5L/day
- Height:-------162-----------------------------------------
- Weight:----------65-------------------------------------
- Body mass index:------24.8-----------------------------
Elimination - Bowel frequency: ----2-----------------Characteristics:sausage shape (type 3)-
Perceived constipation: none
- Urinary frequency:----3-----------/day
- Urinary assistive devices: none -----------------------------------------------------
- Color of urine:-------none--------------------------------------------------------------
Sleep quality - Sleep hours: Naps 1____ Night7____
- Complain:-----------------------------------------------------------------------------
Level of activity: - Independent: ( )
- Partial dependent: ( ) Specify……..
- Dependent: ( ) Specify…………
Other concerns/complains:

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
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 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
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
aortic: anterior P: pulmonary Gallops
Erbs point Equal Clearly Audible Muffled Murmur
Unequal
Gallops
T/M (S1 “lub”) No Clearly Audible Muffled Murmur
Yes
T: tricuspid M: mitral Gallops
Apical rate Normal Abnormal
Apical Rhythm No Yes regular irregular
PMI located No Yes
Capillary 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
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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 No Yes Urinary Catheterization
devices(internal or external) Urinary Condom
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 (level of consciousness) 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 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
4 Withdraws from pain
Motor Response 3 Abnormal (spastic) flexion, decorticate posture
2 Abnormal Extension (rigid) response, decerebrate
posture
1 None
Total/ Comment

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 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 ______

Risk Level Morse Fall Scale Score
Low Risk 0 – 24
Medium Risk 25 – 44
High Risk 45 and higher

▪ Test of cranial nerves

Nerve Nerve name Nature of the Nerve function Specify (what specific test
number nerve (sensory, (normal or was done and what was the
motor, mix) abnormal) response)
Olfactory Sensory Normal The patient can smell fragrance
I.
Optical
II. Sensory Normal The pupils shrink when the light
direct to it
Oculomotor
III. Motor Normal He can move his eyes in4 ways
(Up dawn left and right )
Trochlear
IV. Motor Normal He can move his eyes in4 ways
(Up dawn left and right )
Trigeminal
V. Mix Normal He can fell the fiery and the touch
in his face and can chew easily
Adbucens
VI. Motor Normal He can move his eyes in4 ways
(Up dawn left and right )
Facial
VII. Mix Normal He can smile and puff his cheek

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 Vestibulocochlear
VIII. Sensory Normal The patient can hear
Glossopharyngeal
IX. Mix Normal The patient has gag reflex
Vagus
X. Mix Normal The patient has gag reflex
Accessory
XI. Motor Normal Can move his shoulders up
and his head left and right
Hypoglossal
XII. Motor Normal Can move his tongue

III- Laboratory & Diagnostic findings:

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

Venous blood gas 0.5-1.5 % 4.4% Hypercapnia

FCOHb
Venous blood gas 95.0-99.0% 82% Hypoxia
sO2
Venous blood gas 70-104 mg/dL 205 mg/dL Hyperglycemia
Glucose

b. Diagnostic studies
Name Date Result
Electrocardiogram Normal heart rate
(ECG) 30/3/2023

Echocardiogram Normal LV either good

(Echo) 2/4/2023 systolic function and LV
hypertrophy with grade II
diastolic dysfunction

IV- List of current medications (maximum 5 medications)

Name Dose Route Frequency Action Main Side effects Nursing Care of main side
effects (mention at least 2)
Lantus 20 unit Sc HS Regulation of glucose Hypoglycemia
metabolism Motor the blood glucose
before giving the insulin

V- List of patient's problems in priority (Nursing diagnosis based on the abnormal findings in the assessment sheet)

No Actual problems Potential problems

1 Smoking Disruption of the blood supply in part of the
brain

2 Insulin resistance
deficient fluid volum
3 Dental crisis Hypoglycemia

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Instructor’s feedback in points:

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

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 Allotte Student’s Grade Comme
Assessment Items d nts
Grade Standard criteria
1st case 1st case
2nd case 2nd case
➢ Bio-socio-demographic data Complete, accurate, interpreted 5
(5)
Complete, accurate, not 2.5
interpreted
Incomplete inaccurate 0
➢ Health history (10) Complete, accurate, interpreted 2
Current Health history 2
Complete, accurate, not 1
interpreted
Incomplete inaccurate 0
General appearance 2 Complete, accurate, interpreted 2
Complete, accurate, not 1
interpreted
Incomplete inaccurate 0
Past history 2 Complete, accurate, interpreted 2
Complete, accurate, not 1
interpreted
Incomplete inaccurate 0
Family history 2 Complete, accurate, interpreted 2
Complete, accurate, not 1
interpreted
Incomplete inaccurate 0
Lifestyle/health patterns/habits 2 Complete, accurate, interpreted 2
Complete, accurate, not 1
interpreted
Incomplete inaccurate 0
➢ Physical Examination (15) Complete, interpreted, relevant 15
All systems Complete, relevant, not 10
interpreted
Incomplete, relevant, interpreted 5 Patient
Sheet Incomplete, relevant, not 2.5 Assessment
interpreted
Rubric
Incomplete, irrelevant, not 0
1st + 2nd interpreted Student’s score =
➢ Laboratory & Diagnostic (5) Complete, accurate, interpreted 5 score/2 =
findings Complete, accurate, not 2.5
interpreted
Incomplete inaccurate 0
➢ List of Current Medications (5) Complete, accurate, interpreted 5
Complete, accurate, not 2.5
interpreted
Incomplete inaccurate 0
➢ List of Patient's Problems (10) Actual 4
Potential 4
Priority ranking 2
Total Grade (50) 50
………………………
Instructor’s signature:-----------------------------------------------

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 Nursing Care Plan Rubric

Allotte Student’s
Assessment Items d Standard criteria Grade/Comments
Grade
➢ Bio-socio-demographic data (1) Complete, accurate &relevant 1
Incomplete & relevant 0.5
Incomplete inaccurate 0
➢ Nursing Diagnosis (7)

Diagnostic Label + Qualifiers + 2 Complete, accurate &relevant 2

(problem) Complete, accurate & irrelevant 1
Incomplete inaccurate & irrelevant 0
Related to + 1 Present 1
Absent 0
Related Factors 2 Complete, accurate, relevant 2
Complete, accurate, irrelevant 1
Incomplete inaccurate 0
Defining Characteristics : 2 Complete, accurate, relevant 2
Objective Data and/or Complete, accurate, irrelevant 1
Subjective Data Incomplete inaccurate 0
➢ Patient goal (2) Measurable, relevant & with time 2
frame
Measurable, relevant & without 1
time frame
Measurable, irrelevant & without 0.5
time frame
Unmeasurable, irrelevant & without 0
time frame
➢ Nursing Intervention (5) Complete, accurate, relevant & 5
with rational
Complete, accurate, relevant & 2.5
without rational
Complete, accurate, irrelevant & 1.25
without rational
Incomplete inaccurate, irrelevant & 0
without rational
➢ Comprehensive/complete 4 100 % of applicable problems 4
plan of care according to 50% - 75% of applicable problems 2
listed problems in the 25 % -less than 50% Less than 1
assessment sheet 50% of applicable problems
Less than 25% 0.5
None 0
➢ List of references Present 1
1
Absent 0
Total Grade (20) 20

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 Nursing care plan (Number-------& Date-------------------)

Student's Name: Shahad moteb Al- motaire……… Student’s ID: 4430005476…………………………….

Patient’s initial: M.A……………………………... Age: 45……………. Gender: male…………. Hospital No:king Salman hospital ……….
Bed No: A………….. Room No: 212.......... Diagnosis: ischemic stroke+DM……………………………............ Admission date: 30/3/2023……………
Rational Evaluation
Goal met/not
Nursing diagnosis Goal & Interventions met
Expected outcomes Specify the
outcomes

Smoking is addictive and Not met

Risk-prone health behavior without an established goal because of not
to change this unhealthy
relate to addictive behavior as The patient try to Discuss with the patient current
behavior, smoking meeting the
evidenced by continuing to reduce his smoking health goals. patient again
cessation cannot be
smoke despite the health effect cigarette for 2 weeks achieved.

Not met
because of not
Oral fluid replacement is
risk for deficient fluid volume indicated for mild fluid meeting the
deficit and is a cost- patient agai
related to and dehydration as effective method for
evidence by the intake 1/2 L - replacement treatment.
Older patients have a
Increase the input of Urge the patient to drink the decreased sense of thirst
and may need ongoing
the fluid 1cup every prescribed amount of fluid
reminders to drink. Being
week for a day creative in selecting fluid
sources (e.g., flavored
gelatin, frozen juice bars,
sports drink) can facilitate
fluid replacement. Oral
hydrating solutions (e.g.,
Rehydralyte) can be
considered as needed.

Deficient Knowledge related Long-acting insulin Not met

to dietary modifications Before discharge, does not have a peak because of not
evidenced by Requests of patient will of action. Insulin meeting the
information demonstrate Explain that long-acting glargine is effective patient again
knowledge of
insulin (Lantus) only for over 24 hours
insulin injection,
symptoms, and need to be injected once
treatment of or twice daily
hypoglycemia and
diet

Not met
Risk of In adequate cerebral because of not
When the patient know
perfusion as evidence by the more about the stroke he meeting the
history of the patient of will be preventing the patient again
having an ischemic stroke At the end of the complications if it
education the Provide an atmosphere of reoccurred
patient will know respect, openness, trust,
more about the and collaboration when
sign and symptoms education the patient
of the stroke

References (Using APA style). Note: Add at least 2 resources from books
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nursing care plans: guidelines for individualizing client care across the life span. Ed. 7. Philadelphia, F.A. Davis Co.
Howard K. Butcher, RN, PhD, Gloria M. Bulechek, Joanne M. Dochterman, Cheryl M. Wagner, (2019)
Nursing Interventions Classification (NIC) Elsevier eBook on VitalSource, 7th Edition
Wagner, M. (2023, January 12). Smoking nursing diagnosis & care plan. NurseTogether. https://www.nursetogether.com/smoking-nursing-diagnosis-care-plan/

Student's Signature……………………..

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 Nursing Care Plan Evaluation Form (NCPEF)
Student’s ID________________ Student’s name: ____________________________
Course title_______________ Clinical setting: _____________________________
PLAN’S EXCEEDS STANDARDS MEETS STANDARD APPROACHING DOES NOT MEET TOTAL
COMPONENTS STANDARDS STANDARDS POINTS
4 3 2 1
BIO-SOCIO- Complete, accurate, Incomplete, accurate, Complete, inaccurate, Incomplete, inaccurate,
DEMOGRAPHIC interpreted. interpreted. interpreted. not interpreted.
DATA

NURSING DIAGNOSIS Required number of nursing
diagnoses written correctly
Actual problem: per NANDA format with
Diagnosis R/T etiology + proper etiology (related to)
evidences (OD&/or SD)*. and sufficient data (AEB)* to
support diagnosis.
Risk problem: NANDA diagnosis are
Diagnosis R/T etiology prioritized based on the based
on the patient
needs/condition.
GOAL/OBJECTIVE Goal and related expected
outcomes related to the
diagnosis; is written
following SMART*
NURSING Identifies at least FOUR
INTERVENTIONS and independent interventions
RATIONALE with scientific rationale
supported by textbook
citations or evidence based
information; interventions are
appropriate for the problem;
Integrates dependent
interventions.
Written correctly but data Written incorrectly but Written incorrectly and
to support (AEB)* the with sufficient data to data is insufficient to
diagnosis is not sufficient. support the diagnosis. support the diagnosis
NANDA diagnosis are NANDA diagnosis are not NANDA diagnosis are
prioritized based on the prioritized based on the not prioritized based on
based on the patient patient needs/condition. the patient
needs/condition. needs/condition.
Goal and related expected Goal and related expected Goal and related expected
outcomes related to the outcomes is correct but not outcomes is not related to
diagnosis but SMART* is related to the diagnosis. the diagnosis and not
not completed. SMART*.
Identifies at least THREE Identifies less than Identifies less than
independent interventions THREE independent THREE independent
with scientific rationale interventions with interventions with
supported by textbook scientific rationale scientific rationale not
citations or evidence based supported by textbook supported by textbook
information; interventions citations or evidence based citations or evidence
are appropriate for the information; interventions based information;
problem are appropriate for the interventions are not
Integrates dependent problem. appropriate for the
interventions. problem.

EVALUATION Data supports if goal is: Data somewhat supports if Data is insufficient to Data do not support if
• Met, goal is: support if goal is: goal is:
• Partially met, • Met, • Met, • Met,
• Not met with appropriate • Partially met, • Partially met, • Partially met,
revisions. • Not met with • Not met • Not met
appropriate revisions
GENERAL Accurate APA* format; 1-2 APA* format error; Many APA* format errors, No APA* formatting;
ORGANIZATION appropriate citations and some inappropriate inappropriate citations and No citations/references;
references. citations and references. references. Grammar inappropriate,
No spelling or grammar Minimal spelling or Many spelling or grammar and many spelling errors
errors. grammar errors. errors. Unreadable handwriting.
Readable handwriting. Readable handwriting. Unreadable handwriting.
TOTAL
*OD: Objective Data, SD: Subjective Data, AEB: As Evidenced by, SMART: Specific, Measurable, Achievable, Relevant, Time Limited, APA: American Psychological
Association

Total score = 24 points

1st Plan score = /24

2nd Plan score = /24

Student’s score: 1st + 2nd ÷ 2 = /24

Evaluator’s name: _______________________________________________________Eva

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 Clinical Nursing Record + Nursing Notes
Student's Name: …………………................................................ Student’s ID: …………………………….
Hospital No:……………. Patient’s initial: ……………………………... Age: ……………. Gender: ………
Bed No: ………….. Room No: .......... Diagnosis: ……………………………............ Admission date: ……………

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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