smart goals

Nursing Initial Assessment

Date: Time: _ Informant: □ Patient □ Other _________________________ Reason for Admission (Pt’s own words): __

Vital Signs T O

R A T

P Reg Irreg

SaO2 R BP Ht Wt BMI Kg

Allergies Allergies Reaction Allergies Reaction Allergies Reaction

Latex? Y or N

Chronic Conditions □ Lung Problems □ Stomach Problems □ Thyroid Problems □ Neurological Problems □ Heart Problems □ Liver Problems □ Vision Problems □ Kidney Problems □ Arthritis □ Diabetes □ Chronic infection Treatment: ________________________________ □ Cancer (Where/Type): ___________________________________________________________ Treatment: __________________________________________ Other Past Medical History and Surgeries: _______________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________

□ Family History – □ NSF □ Heart Disease □ Hypertension □ Diabetes □ Stroke □ Seizures □ Kidney Disease □ Liver Disease

Medications Medication

(include OTC) Dose Frequency Taken

today? Y or N

Brought with? Y or N

Medications (include OTC)

Dose Frequency Taken today? Y or N

Brought with? Y or N

Social History □ Lives Alone □ Lives With: ______________________________________________________________________________ Stairs At Home? □ Yes □ No Sleep Pattern: _______________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Immunizations Current? □ Yes □ No Last Tetanus Toxoid: _______________________________________________________________________________

Nicotine Use: □ No □ Yes – How much? ___________________________________ How Long? ________________________________________ Do you live in a smoking environment? □ Yes □ No Alcohol Use: □ No □ Yes – How much? ____________________ How Long? ____________________ Last Drink? ______________________________________________ Social Drug Use: □ No □ Yes – Type? Frequency?__________________________________________________ Support Services: □ No □ Yes – Type □ HHC □ Hospice □ Other ___________

Additional Help needed? □ No □ Yes – Referral made to

6 24 24 19 50

Due to a fall and fracturing her hip

99 NA 88 97 15 136 82 152cm 104 WNL 47.6

O

N A

Osteoporosis

EnoxaparinSodium 40mg daily Y YDocusatesodium 100mg daily Rotoxifene 60mg N Morphinesulfate 4mg 4hr5PRN N

WNL

Yes No

Yes No

Yes No

Impaired hearing

Hearing Aid R L

Walker

Impaired vision

Glasses

Crutches

Can perform ADL?

Contacts

Wheelchair

Can read?

Dentures

U L

Cane

Can write?

Partial

Prosthesis

Home O2 Rate:

Other:

Dietary Habits Special Diet: ________________________________________________________________________________ Supplements: _________________________________________________________________________________

ID Band On? □ Yes □ No Oriented to Unit? □ Yes □ No Call Bell Within Reach? □ Yes □ No IV Pump? □ Yes □ No Toiletry Supplies Offered? □ Yes □ No Skin Integrity Assessment Scale: ______________________________________ If 17 or below, Skin Risk initiated. Fall Risk Assessment Scale: _______________________________ If above 25, Fall Prevention initiated. Skin Risk Assessment Scale:

Sensory Perception Ability to respond to pressure related discomfort

1. Completely limited – unresponsive to pain or limits ability to feel pain over most of body

2. Very limited – response to painful stimuli or limits ability to feel pain over ½ of body, or paralysis present

3. Slightly limited – response to verbal command but can’t always communicate

4. No Impairment – able to verbalize feelings and complaints

Moisture Skin exposed to moisture

1. Constantly moist – (i.e. perspiration, urine)

2. Very moist – extra linen change 1x per shift

3. Occasionally moist – linen change 1x per day

4. Usually dry – no extra linen changes

Activity Degree of physical activity

1. ABR

2. Chair fast – NWB/WC must be assisted to chair

3. Ambulates occasionally – with assist up in chair

4. Ambulates frequently

Mobility Ability to change and control body position

1. Completely immobile

2. Very limited – unable to make frequent changes independently

3. Slightly limited – makes frequent slight changes for self

4. No limitations

Nutrition Food intake pattern

1. Very poor – NPO, Clear liquids, or IVs > 5 days. Takes fluids poorly. Underweight, malnourished.

2. Inadequate – eats < ½ meal. Takes less than optimum

3. Adequate – eats > ½. Tube feeding or TPN provides needs

4. Excellent

Friction

1. Problem – requires assist in moving. Frequent friction. History of skin tears or pressure sores.

2. Potential – requires minimum assist, occasional friction

3. No apparent problem – BRP

4. Up ad Lib

Fall Risk Assessment Scale:

Confused - disoriented - hallucinating 20 Post-op condition - sedated 10 Narcotics, diuretics, antihypertensives, etc. 10

Unstable gait, weakness

20

Drug or alcohol withdrawal

10

Bowel, bladder urgency - incontinence

10

Hx of syncope or seizures

15

Use of walker, cane, crutches, etc.

10

Age 70 or above

5

Recent hx of falls

15

Postural hypotension

10

Uncooperative, impaired judgement

5

Age 12 or younger

15

Poor eyesight

10

Language barrier

5

Paralysis, hemiplegia, stroke 15 New meds (i.e. sedative, antihypertensive) 15 Poor hearing 5

Impairment / Disabilities

Safety

i i u

i y i r

ri NITA

i v r

295

* NSF = No significant findings Check appropriate box if present – if box not checked, sign/symptom not present

Eyes: □ WNL □ Yes □ No Blurred Vision □ Yes □ No Double vision □ Yes □ No Inflammation □ Yes □ No Pain □ Yes □ No Color Blind □ Yes □ No Itching □ Yes □ No Pupils Abnormal □ Yes □ No Drainage -- Color Amount

Ears: □ WNL

□ Yes □ No Other

□ Yes □ No HOH (R) (L) □ Yes □ No Deaf □ Yes □ No Tinnitus □ Yes □ No Dizziness □ Yes □ No Drainage □ Yes □ No Sense of Balance □ Yes □ No Pain

□ Yes □ No Other Nose: □ WNL

□ Yes □ No Congestion □ Yes □ No Pain □ Yes □ No Sinus Problems □ Yes □ No Nasal Flaring □ Yes □ No Alignment □ Yes □ No Nosebleeds – Frequency □ Yes □ No Drainage – Color Amount □ Yes □ No Other

Mouth: □ WNL □ Yes □ No Halitosis □ Yes □ No Pain □ Yes □ No Bleeding Gums □ Yes □ No Lesions □ Yes □ No Sense of Taste Dental Hygiene Last Dental Exam

Throat/Neck: □ WNL □ Yes □ No Sore Throat □ Yes □ No Hoarseness □ Yes □ No Lumps □ Yes □ No Swollen glands □ Yes □ No Stiffness □ Yes □ No Pain □ Yes □ No Dysphagia □ Other

Neurological: □ WNL □ Yes □ No Cooperative □ Yes □ No Memory Changes □ Yes □ No Dizziness □ Yes □ No Headaches □ Yes □ No Oriented □ Yes □ No Other Oriented to: □ Yes □ No Person □ Yes □ No Place □ Yes □ No Time Pupils Size: Deviation:

□ Yes □ No PEARLA Reaction: □ Brisk □ Sluggish □ No Response

LOC □ Alert □ Confused □ Sedated □ Somnolent □Comatose □ Agitated □ Other Speech □ Clear □ Slurred □ Aphasic □ Dysphasia □ None □ Other: Grips: Foot pushes: Gag reflex: □ Other:

Respiratory: □ WNL Lung sounds: Dyspnea □ None □ With activity □ At rest □ Lying down □ Retractions Cough □ None □ Non-productive □ Productive – Color Amount Chest Symmetry □ Yes □ No – □ Barrel □ Funnel □ Other □ Yes □ No Night Sweats □ Yes □ No Hemoptysis □ Yes □ No Cyanosis – Where □ Other:

Cardiovascular: □ WNL Cardiac Rate or Monitor pattern: □ Regular □ Irregular □ Irregularly irregular □ Yes □ No Chest Discomfort – Where: Intensity (1 - 10) Onset

Duration Resolution □ Yes □ No Pulse Radial (R)/(L) □ Yes □ No Pulse Pedal (R)/(L) □ Yes □ No JVD (R)/(L) □ Yes □ No Edema – Location □ Pitting □ Non-pitting □ Yes □ No Pacemaker – Date Inserted Type: Where: □ Yes □ No Murmur

Skin – Extremities – Musculoskeletal: □ WNL Skin □ Warm □ Cool □ Dry □ Firm □ Flaccid Color: □ Yes □ No History DVT □ Yes □ No Homans (R)/(L) Extremities □ Yes □ No Tingling □ Yes □ No Weakness □ Yes □ No Deformity □ Yes □ No Contractures Joints □ Yes □ No Pain □ Yes □ No Stiffness – Location:

□ Yes □ No Replacement – Date Where: ROM □ WNL □ Other (location/ range):

Part II – Systems Review

r e r

r r

E F f f

5mm J NO

or

y

E r r

____

Physical Findings: □ WNL Describe and graph all abnormalities by number: 1. Bruises

2. Incisions

3. Lacerations

4. Rashes

5. Decubitus

6. Dryness

7. Scars

8. Lesions

9. Abnormal color

10. Other :

11. Tattoos

12. Body Piercing

13. Skin Tear/ Duoderm/Op-Site

Gastrointestinal: □ WNL Bowel sounds

Appetite □ Good □ Poor □ Recent change Last BM Date: Color Frequency: □ Yes □ No Laxative use – Type Frequency How long □ Yes □ No Constipation □ Yes □ No Diarrhea □ Yes □ No Nausea □ Yes □ No Vomiting □ Yes □ No Distention □ Yes □ No Hemorrhoids □ Yes □ No Heartburn □ Yes □ No Flatus □ Yes □ No Colostomy □ Yes □ No Ileostomy □ Yes □ No Pain □ Yes □ No Rectal Bleeding □ Yes □ No Weight gain/loss – Reason:

Genitourinary: □ WNL

Color of urine □ Yes □ No Odor □ Yes □ No Frequency □ Yes □ No Flank pain □ Yes □ No Burning □ Yes □ No Difficulty starting □ Yes □ No Urgency □ Yes □ No Incontinence □ Yes □ No Itching □ Yes □ No Nocturia □ Yes □ No Urostomy □ Yes □ No Hx of calculi □ Yes □ No Hx UTI □ Yes □ No Foley – Date 1c

Reproductive: □ WNL FEMALE

LMP G P A Last PAP □ Yes □ No Birth control

□ Yes □ No Menopausal – How long? □ Yes □ No Hormone replacement □ Yes □ No Lesions □ Yes □ No Vaginal discharge □ Yes □ No Itching □ Yes □ No Dysmenorrhea □ Yes □ No□ Amenorrhea □ Yes □ No Hx STD exposure Breast □ Yes □ No Do SBE Monthly? □ Yes □ No Lumps Last Dr. exam Last mammogram

□ Yes □ No Breast feeding □ Yes □ No Nipple discharge □ Yes □ No Family Hx □ Yes □ No Dimpling □ Yes □ No Symmetry □ Yes □ No Nipple inversion □ Yes □ No Pain

MALE Last prostate exam Last PSA

□ Yes □ No Penile discharge □ Yes □ No Hernias

Y

um

NA NA NA NA NA

NIA NIA

□ Yes □ No Sores □ Yes □ No Testicular lumps □ Yes □ No Hx STD exposure Hygiene Breast □ Yes □ No Pain □ Yes □ No Lumps □ Yes □ No Swelling □ Yes □ No Nipple discharge

Hematological: □ WNL

□ Yes □ No Bruising □ Yes □ No Anemia - Hx □ Yes □ No Anemia - Current □ Yes □ No Blood Transfusion - Hx □ Yes □ No Anticoagulant use

r r r

e r r r

Does the patient have an Advanced Directive? □ No □ Yes – Is copy on file? □ No □ Yes - Where? Advanced Directive form on chart? □ Yes □ No – Explain Additional information given? □ Yes □ No – Explain

What does the client (patient/family) say about their learning style? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ According to your textbook, how will you teach a client with this learning style? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

_______________________________________________________________________________________________________ How do you know this client is ready to learn?

Pt Statements:

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Pt Body Language:

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Intrinsic Motivators:

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Extrinsic Motivators:

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Pt’s Ability to learn (cognitive, physical condition, literacy, etc.):

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

After reviewing all of the above, is your client ready to learn? Why or why not?

____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

Advanced Directive

Patient Education

Patient shows active engagement

Demonstrations and questions

Patient is not in any pain or discomfort

Normal

Autonomy

None

no cognitive impairment

Yes patient is attentive and understanding

ANALYZE What do you plan on teaching this client? (Learning Goal) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What data did you base this decision on? (Be specific) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What resources will you give your client? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ How will you use these resources based on your client’s learning style? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ R.N. Signature: ___________________________________________________________________________________________ Date: ________________________________________ Time: _______________________________________

fall risk safety at home assisted support follow with PCP continuemedication as prescribed properwoundcare at homeand avoid movement that maydislocate the

fracture

Patient history of 10years osteoporosis recent hip fracture due to fall

Popedingssifthgedevices proper physicaltherapy proper wound care or

client was able to understand nurse recommendation and willfollow safetyplan

daylpays 6 24 24 20 20

Which NCLEX Category has the highest weight on the exam?