Nurse Assessment
Initial Assessment
Reassessment
Nurse Name
First Name
Last Name
Client Name
Date
Vital Signs
After Rest
After Activities
T
AP
R
Pulse Oximetry
Weight
Height
BP (Right)
BP (Left)
Back
Next
Homebound Status:
Assessment Factors
Subjective/Objective Findings
General Management
ADL Ability (See Functional Assessment Form)
Management & Evaluation (Only for Management and Evaluation Patients)
Multiple Disease Process
Multiple Medications
Multiple Exacerbation
Intense Personal Care Requirements
Nursing Diagnosis
Alteration in Systems Review : Impaired ADL Ability
Compromised Medical Safety
Complex Medical History
Potiential for Complications
Back
Next
Assessment Factors: Knowledge Deficit
Technical Procedures
Medications
Disease Process
S/S to Report to M.D.
Diet/Fluid Rest
Basic Care Principles
Home Safety
Infection Control
Equipment Use
Emergency Preparedness
Nursing Diagnosis
Knowledge Deficit
Pain (Type)
Mild
Moderate
Severe
Frequent
Infrequent
Location (specify)
Relived by (specify)
Aggravated by(specify)
Nursing Diagnosis
Altered Pain Control
Back
Next
Assessment Factors
Subjective/Objective Findings (check apllicable items)
Neurological/Psychosocial
Alert
Oreiented(specify)
Confused
Person
Forgetful
Anxiety
Lethargic
Place
Hallucenation
Coma
Depressed
Time
PEARL/Pupils
Paralysis (specify)
RUE
LUE
RLE
LLE
Grasp (specifiy)
PT
LT
Tremors
Memory (specifiy)
Adaquete
Fair
Poor
Sleep Habits (specify)
Sleeps Well
Restless
Up Frequently
Takes Naps/when
Change In (specify)
Loneliness
Isolation
Role Change
Body Image
Interpersonal Conflict
Finacial Problems
Eating Habits
Grief
Coping Skills
Speech (specify)
Clear
Slurred
Aphasic
Vision (specify)
Adequate
Poor
Glasses
Blind
Hearing (specify)
Adequate
Poor
Hearing Aid
Deaf
Headache
Vertigo/Diziness
Numbness
Gastrointestinal
Nausea/Vomitting
Diarrhea
Abdominal Pain/Cramps
Constipation
Impaction
Incontinence
Tarry/Bleeding/Abnormal Stools
Bowel sounds (specify)
WNL
Hyperactive
Hypoactive
Ostomy
NG/Gastronomy
Dysphasia
Appetite (specify)
Good
Poor
Fair
Last BM (specify)
Nursing Diagnosis
Alteration in Bowel Function
Alteration in Fluid Volume
Alteration in Comfort
Alteration in Nutrition
Genitourinary
Pain/Burning
Hesistancy
Incontinence
Frequency
Urgency
Hematuria
Distention/Retention
Catheter Size (specify)
Urine (specify)
Odor
Clarity
Color
Output(specify)
Adequate
Inadequate
Rash
Discharge
Itching
Nursing Diagnosis
Alteration in Urinary Elimination
Potential for Infection
Alteration in Comfort
Musculoskeletal
Ambulatory
Non-Ambulatory
Weight-bearing (specify)
Full
Partial
Non-weight-bearing
Generalized Weakness
Gait(specify)
Slow
Steady
Unsteady
SOB/Fatigue with
________ ft.
Pain
Activity (specify)
Sleeps
Stays in Bed
Sits all Day
Takes Naps
Ambulates Short Distance
Nursing Diagnosis
Imparied Mobility
Alteration in Comfort
Activity Intolerance
Back
Next
Assessment Factors
Subjective/Objective Findings
Lung Sounds (RUL)
Clear
Decreased
Lung Sounds (RML)
Clear
Decreased
Lung Sounds (RLL)
Clear
Decreased
Lung Sounds (LUL)
Clear
Decreased
Lung Sounds (LLL)
Clear
Decreased
Nursing Diagnosis
Alteration of Respiratory Status
Impaired Gas Exchange
Alteration in Tissue Perfusion
Potential for Infection
Activity Intolerance
Back
Next
Nutrition
Diet(specify)
Regular
GM NA
Lo Chol
Lo Fat
Calorie ADA
Other (specify)
Supplements(specify)
Fluid Restriction
Yes
No
If yes specify
cc/day
Shopping Done by (specify)
Self
Others
Economic Hardship (specify)
Yes
No
Dentures (specify)
Upper
Lower
Caries (specify)
Yes
No
Chewimg Difficulties
Swallowing Difficulties
Adequate Oral Hygiene (specify)
Yes
No
Comments
Nursing Diagnosis
Alteration in Nutrition
Impaired Skin Integrity
Alteration in Elimination
Feeding Tube
Nursing Diagnosis
Altered Nutritional Status
Altered Hydration Status
Altered GI Status
Ostomy Care
Nursing Diagnosis
Altered GU Status
Altered GI Status
Nurse signature:
Date
/
Month
/
Day
Year
Date
Patient signature:
Date
/
Month
/
Day
Year
Date
Back
Next
Assessment Factors
Subjective/Objective Findings
Integumentary/Skin
Pallor
Cyanosis
Flushed
Hydration (specify)
Adequate
Fair
Poor
Thin and Fragile
Tugor
Good
Fair
Poor
Wound/ Incision
Rows
Location
Size
Depth
Drainage
1
2
3
4
5
6
Other Health Summary Findings
Reproductive
Breast Lumps
Abnormal Pap Smear
Penile Discharge
Nipple Discharge
Vaginal Discharge
Prostate Discharge
Menopause
Iregular Menses
Nursing Diagnosis
Alteration in Comfort
Alteration in Elimination
Disturbance in Self Concept
Sexual Dysfunction
Cardiovascular
Arrhythmia
Angia/Chest Pain
Syncope/Lightheaded
Distention
Neck Bein
Rhythm (specify)
Pedal Edema Right(specify)
None
Trace
+1
+2
+3
+4
Pedal Edema Left(specify)
None
Trace
+1
+2
+3
+4
Pedal Pulse Right (specify)
None
Weak
Strong
Pedal Pulse Left (specify)
None
Weak
Strong
Color
Normal
Pink
Red
Pale
Dusky
Warm/Cool to Touch
Other (specify)
Nursing Diagnosis
Altered Cardiac Status
Altered Fluid Volume
Alterartion in Comfort
Alteration of Vascular Status
Submit
Should be Empty: