Syllabus

Lab

Clinical

Appendix
 

Name__________________________     Age ____            Sex_________ 
Marital Status___________________      Race____________________ 
Occupation_____________________      Religion_________________ 
Place of Employment________________________________________ 
Education______________________ 
 

Health History 
Check the problems that you presently have or have had. 
_____ Anemia 
_____ Bronchitis or Pneumonia 
_____ Cancer 
_____ Liver disease 
_____ Diabetes 
_____ Emphysema 
_____ Heart disease 
_____ High Blood  pressure 
_____ High cholesterol 
_____ Obesity ( more than 20 
           Pounds overweight) 

In the past year have you had: 
   Yes              No 
______        _______  chest pain on exertion relieved by rest? 
______        _______  shortness of breath lying down that was 
                                     relieved by sitting up? 
______        _______  unexplained weight loss of more than 10 
                                    pounds? 
______        _______  unexplained bleeding? 

List medications that you take on a daily basis: 
 
 
 
 
 

List any surgeries that you have had: 
 
 
 
 

Family History 
Check problems that apply to your blood relatives. 
___ Cancer                                           ___ High blood 
                                                                    pressure 
___ Diabetes                                        ___ Stroke 
___ Heart disease                                 ___Tuberculosis 

Social History 
List immediate family members, age, & general health status: 
 
 
 
 
 

Functional Health Pattern Assessment 
1. Health perception & Health Management 
How has your general health been? 

Describe the most important things you do to stay healthy: 
 
 

What questions or concerns do you have about your health at this time? 
 

Do you... 
Y    N   have yearly dental examinations? 
Y    N   have your eyes checked regularly? 
Y    N   examine your breast for signs of cancer monthly? (Female) 
Y    N   conduct monthly testicular self examinations? (Male) 
Y    N   smoke? 
Y   N    avoid sun tanning and wear a sunblock? 
Y    N   know and understand safe sex precautions? 
Y    N   know the 7 signs of cancer (CAUTION)? 
Y    N   wear seat belts? 

2. Nutritional and metabolic pattern 
Are you on a special diet of any type? ____________________________________________ 

Describe a typical daily diet: 
BREAKFAST                                                          LUNCH 
 
 
 

DINNER                                                                  SNACKS 
 
 
 
 
 
 
 
 

Do you... 
Y   N   limit intake of high cholesterol foods and saturated fats? 
Y   N   eat a high (20-30 grams) fiber diet? 
Y   N   eat at least one uncooked fruit or vegetable per day? 
Y   N   limit intake of refined sugar (desserts, junk foods)? 
Y   N   drink 3 or less cups of coffee per day? 
Y   N   drink 5 or less soft drinks per week? 
Y   N   drink no more than one alcoholic beverage per day? 
Y   N   have at least 3 servings of calcium rich food/drink per day? (Milk, cheese, yogurt, etc) 
 
 

3. Elimination pattern 

Y  N   Have you had a change in your bowel or bladder habits recently? 
           If yes, describe: 

How often do you use laxatives? 
 

4. Activity and Exercise pattern 
Do you feel that you have sufficient energy for desired and required activities? 
 

Describe your daily pattern of activity including leisure time activities: 
 
 

Do you exercise?  Type    Frequency 
 

Do you... 
Y   N   take the stairs rather than an elevator? 
Y   N   participate in any aerobic activity or sport at least 3 times a week for 30 minutes? 
Y   N   do stretches and warm-up exercises before strenuous exercise? 
Y   N   think that your height has decreased since menopause (older females only)? 

5. Sleep and rest pattern 
Describe your sleep pattern (time that you go to bed and time that you wake up, naps, etc) 

Y   N   Do you generally feel rested and ready for daily activities after sleeping? 

6. Cognitive and perception pattern 

Do you... 
Y   N   have any difficulty hearing? 
Y   N   have any difficulty seeing? 
Y   N   have any changes in memory? 
What is the easiest way for you to learn new things?(reading, listening, etc) 

7. Self perception and self concept/ role & relationship patterns 
How would you describe yourself? 
 
 
 
 

Do you find it easy or difficult to communicate with others? 

Do you enjoy being with family and friends?  What social groups do you belong to? 
 

8. Coping and Stress Tolerance pattern 
How many times per week do you generally feel tense or stressed? 

 What causes stress for you? Have there been any big changes in your life recently? 

Are you able to say no without feeling guilty? 

 How do you cope with stress? Do you practice any methods of relaxation, meditation, yoga? 
 
 
 
 
 
 
 
 
 

 Nursing Assessment Database, Part 2 : Screening Physical Exam

1.  General Survey 
 Describe general appearance of client including state of consciousness, speech, body movements & stature, nutritional status: 
 
 

2.  Measurements 
Height_______       Weight _________          Ideal Weight___________ 
 

3.Vital signs 
Blood pressure_________ Radial pulse__________ Respiration____________ Temperature__________ 

4. Skin, Hair, & Nails 
Skin color___________ Moisture____________ Turgor________________ 
Edema? NO  YES- location & grade: 

Describe hair color, thickness, & texture: 
 

Describe any lesions, scars, bruises that you see: 
 

4. Head & Neck 
Cranial Nerve Assessment 
I.  Sense of smell:    intact _________        diminished __________ 
II.  Visual acuity :     can read ___________ 
 can only recognize faces_____________      blind__________ 
III.  Pupils:    equal ? yes____ no____    react to light ? yes_____ 
                                                                                        no  _____ 
V. Sensation of face intact? yes_____ no______ 
IV., VI. Extra ocular movement :  able to direct gaze 
        down/right? yes ____no _____   down/left?  yes____ no_____ 
        up/right? yes______ no ______   up/left? yes______ no_____ 
        left?  yes____ no____   right? yes______ no______ 
VII   Smile symmetrical? yes _____ no ____ 
Able to purse lips? yes____ no ____ 
VIII.  Sense of hearing:    able to hear whispered  word________ 
                                      must speak loudly_______deaf__________ 
XI.  Shoulder shrug symmetrical?  yes_____ no______ 
XII.  Able to move tongue side to side?  yes______ no_______ 

Mouth & Nose: list any abnormalities such as lesions, discharge, areas of irritation, bleeding, missing or loose teeth, swollen gums: 

5. Extremities 
 
 

Strength*	Strength*	Range of Motion	Presence of Joint  Pain/Swelling
Shoulders	.	.	.
Elbows	.	.	.
Wrists	.	.	.
Fingers	.	.	.
Hips	.	.	.
Knees	.	.	.
Ankles	.	.	.

 

*Criteria for grading muscle strength: 
No evidence of contractility = 0 
Evidence of slight contractility=1 
Complete ROM with gravity eliminated  = 2 
Complete ROM with gravity = 3 
Complete ROM with some resistance = 4 
Complete ROM  with full resistance = 5 

Document any areas of numbness or tingling: 
 

Motor status: 
1.  Describe gait 
2.  Toe walk 
3.  Heel walk 

Coordination: 
1.  Finger to nose 
2.  Romberg’s test 

Homan’s sign     positive_________ negative_______ 
Post Tibial  Pulse (strength) +_________ 
Dorsalis Pedis Pulse (strength) + _________ 
Capillary Refill _______ seconds