Syllabus

Lab

Clinical

Appendix
 

Name__________________________     Age ____            Sex_________   Race_______________ 
Are you presently working?______  What types of work did you do in the past? 

Education______________________ 
Where do you presently go for medical care? 
 

Health History 
Check the problems that you presently have or have had. 
_____ Anemia 
_____ Pneumonia, TB, or emphysema 
_____ Cancer 
_____ Liver disease 
_____ Diabetes 
_____ Skin conditions that require treatment- rash, athlete's foot 
_____ 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 any surgeries that you have had: 
 

List medications that you take on a daily basis: 
 

 Immunizations & Screening: 
 Last PPD (skin test for TB)______(-)(+) 
Chest x-ray  Y  N        Treated?  Y  N 
                                   TB meds taken____________________________ 
                                     For how long? 

Tetanus vaccine__________  Flu vaccine________ 
Pneumococcal vaccine________________________ 

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? 
 

What are your major health concerns now?  What do you have questions about? 
 

Describe the most important things you do to stay healthy: 
 

Do you... 
Y    N   know the 7 signs of cancer (CAUTION)? 
Y    N   have yearly dental examinations? Last exam__________ 
Y    N   have your eyes checked regularly? Last exam_________ 
Y    N   examine your breast for signs of cancer monthly? (Female) 
                     Date of last mammogram ____________ 
                     Date of last pelvic exam, PAP test___________ 
Y    N   conduct monthly testicular self examinations? (Male) 
Y    N   smoke? 
             How much do you smoke each day?_________________ 
             How long have you been smoking?__________________ 
             Have you ever tried to quit smoking? Y  N  For how long? 
             Would you like to stop smoking now? Y  N 
Y    N   know and understand safe sex precautions? 
             How often do you use condoms? 
                 Always           Sometimes           Never 
             Females- What method of birth control are you using? 

Would you like information on HIV and/or sexually transmitted diseases? 
 
 
 

2. Nutritional and metabolic pattern 
Are you on a special diet of any type? ____________________________________________ 
How many meals do you eat per day?_______________ 
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 or 3-5 servings of 
                fruit/vegetables  per day 
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   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 enough energy for desired and required activities? 
 

Describe your daily pattern of activity: 
 
 

Do you exercise?  Type    Frequency 
 
 
 

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

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 others?  Who are you closest to? (family, friend, etc) 
 

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? 
 

 How do you cope with stress? 
 
 
 
 
 
 
 
 
 

 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 
 

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