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HEALTH ASSESSMENT DATA

Student Name: ncah PART A: COLLECTION FORM
Date: Je GthHEALTH HISTORY AND DETERMINANTS OF HEAL
Date of Admission: )
Room: B41
Code Status: Full code
Patient Initials: Age: 74
Marital Status:
Allergies: ASA C do Reaction:
If changed, how recently?
Unknown
Languages Spoken and Written:
Source of Information: Education:
pPatient DChart RKardex o Family o Other: rast and Present (Occunation(s) an roles:

Reason for Admission, Onset,Duration, Pt.'s

nerception: Where was thenerson born? If bornoutstu
Underlying Pathophysiology: Canada, how long has the person lived in
Canada?

Manifestations (Signs and Symptoms): Has the person travelled to other countries in
Right g sueling, ythe-itna aud kely
fendemas, Pt has
relatad fo
the last 6 months? If so where?

No tve ultu
tst,. Location currently living and for how long?
asistahce Ratet
}:oviguly. reree ip
Secondary Health Problem &lor Complications: Cultural and Religious Norms & Values:

Developmental Stage:
Older Adult.
Medications: Clinical Indications & Nursing Implications Living
Ticogrelor, 90 ma - Po,BD Arrangements (type of
house/apartment/stairs): ere

Po. aAN How does the Patient's living environment

Buopiolo - 1 5 g. impact their health?. NA
Entret, co ated
Tan
AA Ent pic Does the Patient feel safe at home?

Pumagg
funseride 20me. PO, GAM
Surgical Interventions, Medical Treatments and Support System: Family, friends,
Procedures: neighbours, community etc:

NIA Health Perspective (Patient & Significant

Other Views)
Diagnostic Tests/Exams: Recent Results & Implications: Health Promotion Teaching:

Interprofessional Team Consultations: Education/ Discharge Planning Needs:

Occupaional Therapist Health Services Available:
cCAC
Socual iciker
Conrno Rroan CaIlao Dracticl ureina Somoctor 1-1 012/n19
 HEALTH ASSESSMENT DATACOLLECTION FORM
PART A: HEALTH HISTORY AND DETERMINANTS OF HEALTH
Student Name: Annak Adnt Date: Patient Initials: Age: y Room:

Date of Admission: Marital Status:

CodeStatus: Full codc
Allergies: ASA
Unknown
Source of Information:
DPaticnt DChart pKardcx
Reason for Admission, Onset, Duration, Pt.'s perception:
Underlying Pathophysiology:
If changed, how recently?
Reaction: LanguagesSpoken and Written:
Fducation:
roles:
Past and Present (Occupation(s) an
oFanmily o 0her:
born outside
Where was the person horn? If
Canada., how Iong has the person lived in
Canada?

countriesin
Has the person traveiled to other
Manifestations (Signs and Symptoms): the last 6 months? If so where?
long?
Location currenty living and for how

Secondary Health Problem &lor Complications: Cuitural and Religious Norms & Values:

Developmental Stage:

Medications: Clinical Indications & NursingImplications Living Arrangements (type of

DO, N a ty house/apartment/stairs):
environment
How does the Patient's living
Enoxopaük impact their health?.
home?
Does the Patient feel safe at

SurgicalInterventions, Medical Treatments and

Support System: Family, friends,
neighbours, community etc:
Procedures:

Health Perspective (Patient & Significant

Other Views)

Implications: Health Promotion Teaching:

Diagnostic Tests/Exams: Recent Results &
C1 rigk leg (NGy 21)
boppler us(2
Interprofessional Team Consultations: Education/ Discharge Planning Needs:
Health Services Available:

019/n10
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Conrno Rrnun ollono Dractiel
 SYSTEM
Neurological/
Cognitive &
Mental/ Emotional
Status
*UR: LefRight
Cardiovascular
*CSM: colour, sensation,
movement:
Respiratory
*ACCO: amount, colour.
consistency.odour
Gastrointestinal
*ACOO: amount, colour,
consistency, odour
*Poor: less than ½ tray eaten
per meal over 24 hours
Genitourinary
*ACCO: amount, colour,
consistency, odour
Musculoskeletal
ntegument
ACCO: amount, colour,
onsistency, odour
in
ASSESSMENT FINDINGS
Level of consciousness: GAlert
DConfuscd o Unresponsive
Orientation (time/place/person): o x3 D
Other(spccify):
MentalStatus (specify):
Speech:oNo deficits o Aphasia
Swallowing: o No deficits o DysphagiaDysarthria
pOther:nOther (spccify):
Sensory ability: o No dcficits
DAbnormal(spccify)
Vision:D No deficits aGlasses/Contacts nCataracts L. /R OBlind L /R Oher(spccily):
Hearing: o No deficits oHearing id L/RO Other (spccify):
Stressors:
Behaviour & verbalization relatcd to situation (specify):
Motor ability: D Ams: uNormal strength L/R* nWcakncss LR nNo movement L/R
DLegs: DNormal strength LR OWeakness L/R ONo Movement L/R
Vital Signs: Temp: BP: Heart Rate: oRadial/Apical L/R oRate
*CSM: DNo CSM deficits x4limbs Xae oRhythm es
D Abnormal CSM-Arms: o Pulses: weak /absent L/R o Colour: Pale/Cvanotic L/R oTemp: Cool L/R
eCap. Refill: >3 sec. L/R DSensation: diminished /absent L/R DMovement: diminished /absent L/R
oAbnormal CSM- Legs: DPulses: weak /absent L/R oColour: Pale/Cyanotic LR OTemp: Cool L/R
DCap. Refill: >2 sec. L/R DSensation: diminished /absent L/R OMovement: diminished /absent L/R
Edema: X Not present oPresent: Location #1RLRG Cellu ltie Type: Dependent/ Pitting Grade
o Present: Location #2: Ley- Pting Type: Dependent/ Pitting Grade
Nail beds/ Mucus Membranes/Conjunctiva: oPink bPale Dcyarotic Other (specify): Skin taut
IVor Saline Lock: Location: Solution/Rate:
Respirations: Rate: 6 oRhythm /Patterm Ne DDepth OSymmetry equal_ o Expansion
Use of accessory muscles: o Breath Sounds: o present o absent A/E onormal cabsent aabnormal
f adventitious sounds present: o crackles o wheezes o both Location:
02 Saturation:21 Oxygen Delivery: zKoom air ONasal prongs rate: OMask Rate:
Cough:oNone oPresent: oproductive onon-productive Sputum: oNone ACCO:
Other: o Tracheostomy -size DChest Tube: RL Suction: DDrainage: ACCO:
Diet/Fluid: o Orders: b DÁssistance: DEnteral/G- Feeds:
Current Weight: (61 (bs ORecent Gains/Losses Ht: BMI Appetite:Good o*Pogr
Oral Cavity: Mucous Membrane/Tongue/iTeeth Condition: o Dentures oNo teeth dParti
Abdomen:SofFirm DFlat/Distended o Bowel Sounds; Present x4 quads oAbsent(specify):
BowelContinence: DContinent o Incontinent o Ostomy (specify):
Bowel Movement: Date of last BM: 9-l2e OBM characteristics (*ACCO):
Hemorrhoids: DPresent dAbsent Other (supplements):
Hydration Status:/Urinary Output < 50 ml/hr o Skin turgor normala
Urinary Continence: dContinent o Incontinent o Ostomy (specify):_
Toileting Method: o Independent oBathroom with assistance aCommode DBedpan/Urinal
DCondom Catheter o Indwelling/Intermittent DCatheter a Briefs
Voiding schedule (specify) :
Urine Characteristics(*ACCO):
Abnormalities: DPain DBurning oFrequency oHesitancy oRetention
Activity Orders: o Non weight bearing Independent Assistance o Total Assistance
Assistive Devices: oNA Walker aCane o Wheelchair o Other (specify):
Mobility Concerns:Weakness/Gait/ ROM/Amputee (specify):Right Ltq Cellulitis
Fall risk (specify):
Hygiene/Grooming: o Independent eAssistancen Total Care OMouthcare o Hairwash o Shave
Skin ASsessment: o Braden Scale Score: Texture: DTrgor:
o Rash/Discoloration/Lumps (specify):
Wounds: o Location #1: Type/Stage: Dressing:
ON/A oLocation #2: Type/Stage: Dressing:
Drains:o Location #1 Type: Drainage *ACCO
ON/A DLocation #2: Type: Drainage *ACCO
Pain Assessment (PQRST):
Pain scale score 4 o Nonverbal Pain Cues:

Infection ControlRoutine Precautions o Additional Precautions (Category):

Fety
Fall Prevention Measures XSiderails o Bed Alarms nSeatbelt o Other(specify):
Restraints: oMD order on chart o Type: Reason for:
Other (smoking etc):

ircina Comoctar 1-A 2012/nN0

Coarno Rrun Cnlloso Dracticsl