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Nursing Assessment Form

This nursing assessment form collects clinical information on a client's medical history, physical assessment, and abilities. It documents diagnoses, vital signs, risk factors, functional limitations, equipment needs, and level of independence with activities of daily living. The comprehensive form is used to develop care plans and ensure home health needs are met.

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Sri widya ningsih
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157 views

Nursing Assessment Form

This nursing assessment form collects clinical information on a client's medical history, physical assessment, and abilities. It documents diagnoses, vital signs, risk factors, functional limitations, equipment needs, and level of independence with activities of daily living. The comprehensive form is used to develop care plans and ensure home health needs are met.

Uploaded by

Sri widya ningsih
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HOME HEALTH SOLUTIONS GROUP

HOME COMPANION SERVICES

NURSING ASSESSMENT FORM

__ Start of Care ___ Recertification ___ Resumption of Care

Date: ______________ RN::____________________________________________

Client:____________________________________________________ MR#_________

Primary diagnosis:_______________________________________________________

Second diagnosis:________________________________________________________

Height:______ Weight:______ Temp:______ Pulse:_____ Resp:______ B/P:________

Allergies:____________________________________ Gender: __male __female

Diet:___________________________________________________________________

Past history:_____________________________________________________________

________________________________________________________________________

Psychosocial Status

Mental Status: Oriented X ______________ Disoriented X ______________________


__Comatose __forgetful __Agitated __Confused __anxious __depressed
Comment:_______________________________________________________________

Risk Factors::
___smoking __obesity ___alcohol dependency __drug abuse __none of the above

10300 Sunset Drive, Suite 236. Miami, FL 33173 T.786.991.2300 F.786.991.2304 www.hhsgroup.net
NURSING ASSESSMENT FORM (Cont.)

Client: ________________________________________________ MR# ___________

Functional limitations: __Amputation _____________ __ Bowel/Bladder incontinence


__contracture __hearing __paralysis __endurance __ambulation __speech __vision
__poor manual desterity __legally blind __dyspnea __poor hand-eye coordination
__unsteady gait __poor balance other:________________________________________
________________________________________________________________________

Activities permitted: __complete bedrest __bedrest/BRP __up as tolerated


__transfer bed to chair __independent in home

Assistive device: __cane __quad cane __walker __ rolling walker __reg. wheelchair
__electric wheelchair __crutches other____________________________________

Equipment at home: __hospital bed __commode __hoyer lift __nebulizer __bath


bench __ apnea machine __oxygen concentrator __suction machine
other_________________________________________________________________

Device/equipment needed at home:__________________________________________

Significant other:_________________________________________________________
________________________________________________________________________

Cardiovascular: __client denies problems


__chest pain __palpitations __vertigo __syncope __pulse deficit __PVD
__cyanosis __claudication __varicose veins __murmur __fatigue
__cardiac pacemaker date__/__/__ last date checked__/__/__ type:________________
__edema:__________________________ other:________________________________

Respiratory: __client denies problems


Lung: __clear __left __ right (wheezes/rhonchi, crackles/rales, diminish /absent)
Capillary refill less than 3 sec/ great than 3 sec, __orthopnea __hemoptysis
__SOB at rest/minimal exertion/moderate exertion/when walking more than 20 feet
__cough productive/non-productive describe:__________________________________
Oxygen @ __ LPM via nasal cannula/mask/trach trach size/type:__________________
Other:__________________________________________________________________

Skin: __client denies problems


Color: __pink __pale __cyanotic __jaundiced Turgor: __poor __good
Temperature: __hot __warm __cool Condition: __dry __moist __ecchymosis
__rasch __petechie __itch __redness __ bruises __scaling
Comment:_______________________________________________________________
Open wound/decubitus/incision/diabetic ulcer location:___________________________

10300 Sunset Drive, Suite 236. Miami, FL 33173 T.786.991.2300 F.786.991.2304 www.hhsgroup.net
NURSING ASSESSMENT FORM (Cont.)

Client: ________________________________________________ MR# ___________

Gastrointestinal/abdomen: __client denies problems


__heartburn __distention __flatulence __nausea __vomiting __constipation __ascites
__cramping __bleeding __anorexia __dysphagia __diarrhea __bowel incontinence
Bowel sounds:________________ Last BM:______________________
Ostomy: ____________________ stoma:______________________________________
Other:__________________________________________________________________

GU/GYN: __client denies problems


__frequency __urgency __incontinence __nocturia __polyuria __dysuria __oliguria
__pain __burning __odor __lithiasis __ hematuria __infections
ostomy:______________________________________________
Catheter:__condon cath __foley cath __suprapubic cath size:____F with ____cc
__mastectomy R/L __hysterectomy __Vaginal bleeding __discharge ___BPH/TURP
Other:_________________________________________________________________

Neurology: __client denies problems


__headache __fine/gross hands tremor __PERRLA L/R ___dominant side R/L
__aphasia __hemiplegia __paraplegia __quadriplegia __numbness __tinting
__seizures __ataxia __syncope __vertigo __dizziness __weakness
Other:__________________________________________________________________

Musculoskeletal: __client denies problems


__fracture:__________________ ___contracture joints:__________________________
__atrophy:__________________ ___decreased ROM:___________________________
Pain: location:________________________________ intensity:1 2 3 4 5 6 7 8 9 10
Duration: _less often than daily __daily, but not constantly __all of the time

Eye: __client denies problems


__impaired vision __cataracts R/L __retinopathy __blind R/L __legally blind
__glasses __contacts R/L ___blurred vision __prothesis R/L __glaucoma
Other:____________________________________________________________

Nose: __client denies problems


__congestion __epistaxis __loss of smell __sinus problem
Other:_____________________________________________________________

Throat: __client denies problems


__dysphagia __hoarseness __lesions __sore throat
Other: _____________________________________________________________

10300 Sunset Drive, Suite 236. Miami, FL 33173 T.786.991.2300 F.786.991.2304 www.hhsgroup.net
NURSING ASSESSMENT FORM (Cont.)

Client: ________________________________________________ MR# ___________

Mouth: __client denies problems


___dentures upper/lower/partial/total ___gingivitis __toothache ___ulcerations
Other: _____________________________________________________________

Activities of Daily Living Unable Minimal Moderate Maximal independent


To do assistance assistance assistance

Ambulation
Stairs
Dressing
Feeding
Household tasks
Transfer
Self-care(grooming/bath)
Toiling

__________________________________ ______________________________
History given by Relationship to client

__________________________________ _____________________________
RN signature Date

10300 Sunset Drive, Suite 236. Miami, FL 33173 T.786.991.2300 F.786.991.2304 www.hhsgroup.net

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