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Home Health Solutions Group Home Companion Services: Nursing Assessment Form - Recertification

The patient has a cough accompanied by shortness of breath and rapid, shallow breathing. The nursing assessment found accumulation of fluid in the left lung cavity. To address ineffective airway clearance, the nurse educated the patient on proper coughing techniques, deep breathing, fluid intake, and collaborated with other providers regarding expectorants, antibiotics, imaging, and asthma medications.

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Citra Puspita Sari
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46 views

Home Health Solutions Group Home Companion Services: Nursing Assessment Form - Recertification

The patient has a cough accompanied by shortness of breath and rapid, shallow breathing. The nursing assessment found accumulation of fluid in the left lung cavity. To address ineffective airway clearance, the nurse educated the patient on proper coughing techniques, deep breathing, fluid intake, and collaborated with other providers regarding expectorants, antibiotics, imaging, and asthma medications.

Uploaded by

Citra Puspita Sari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, 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: November 11,2O2O RN::_______

Client:Ny. M MR#______

Primary diagnosis: cough accompanied by shortness of breath

Second diagnosis: T he patient shows rapid and shallow breathing

Height: 168 cm weight: 68kg Temp: 36 C Pulse Resp:100x/minute B/P:120/80mm/Hg

Allergies:- Gender: __male(√)female

Diet:-

Past history: The patient said that he had suffered from tuberculosis

________________________________________________________________________

Psychosocial Status

Mental Status: Oriented X (√) Disoriented X (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: Ny. y 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: Ny. Y 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: Ny. Y MR# ___________

Mouth: (√) client denies problems


___dentures upper/lower/partial/total ___gingivitis __toothache ___ulcerations
Other:cough accompanied by shortness of breath

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 Tn. x Relationship to client (husband)

October 26,2020
__________________________________
RN signature
DIAGNOSE: Airway clearance is not effective

DS:The patient says it is difficult to breathe or is short of breath when coughing with thick
secretions

DO: The patient shows rapid and shallow breathing.


RR 28 times / minute Pulse 100 beats / minute, Semi fowler position.
The results of the examination on the chest percussion there is an accumulation of fluid in the left
thorax cavity.

INTERVENTION: Explain the client about the effective use of cough and why there is a build-
up of secretions in the sal. Respiratory.
- Teach the client about the proper method of controlling cough
- Breathe deeply and slowly while sitting as straight as possible.
- Do diaphragmatic breathing.
- Hold your breath for 3-5 seconds then slowly, remove as much as possible through the mouth.
- Do a second breath, hold and cough from the chest by doing 2 short, strong coughs.
- Lung auscultation before and after the client coughs.
- Teach the client actions to reduce the viscosity of secretions: maintain adequate hydration;
increase fluid intake 1000 to 1500 cc / day if not contraindicated.
- Encourage or provide good oral care after coughing.
- Collaboration with other health teams: With doctors, radiology and physiotherapy. About:
 Giving expectoran.
 Antibiotics.
 Consul chest photo.
 Giving anti-asthma

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