KEY KINGSBOROUGH COMMUNITY COLLEGE

N/A - Not Applicable DEPARTMENT OF NURSING

NIC – Not in Chart
UTD – Unable to Determine
Ø - None

NURSING ASSESSMENT
STUDENT________________________________________ CLIENT INITIALS __________________________________________
INSTRUCTOR______________________________________ ROOM NO_________________________________________________
AGENCY/SECTION_________________________________ DATES OF CARE ___________________________________________

DIRECTIONS: Please fill in each line/space. Nothing should be left blank.

DATA COLLECTION: HISTORY & HEALTH ASSESSMENT

PRESENT ILLNESS - Chief Complaint (Admission date, reason for seeking care, pt. explanation)

_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

HISTORY OF PRESENT ILLNESS - (When started, description of problem, location, character, severity, timing, aggravating or relieving factors,
associated factors, client’s perception of what the symptom means)
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

MEDICAL DIAGNOSIS:_______________________________________________________________________
CONCURRENT HEALTH PROBLEMS: ___________________________________________________________
PAST MEDICAL HISTORY:
Childhood Illness_________________________________________________________________________________________________________________
Infectious Diseases ______________________________________________________________________________________________________________
Immunizations (Childhood, Hep B, Influenza, Pneumococcal, last Tetanus & TB test) _______________________________________________________
Prior Hospitalizations (Reason, Treatment, Length of Stay)
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
History of: Anemia, Asthma, Cancer, Cardiac Disease, CVA (stroke) Diabetes Mellitus, Emphysema, Kidney Disease, Falls, Fractures,Genetic Disease,
Hepatitis, Hypertension, Mental Illness, Sexually Transmitted Diseases, Tuberculosis.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

PAST SURGICAL HISTORY: (Type, Date, Place, Length of Stay)

_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

TRANSFUSIONS (Dates)___________________________________ REACTIONS(Describe) ________________________________________

MEDICATIONS PRIOR TO ADMISSION: (Prescribed, Over the Counter, Vitamins, Herbs, dose and frequency)

_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

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ALLERGIES:
Medications:________________________________________________________________________________________________________
________________________________________________________________________________________________________
Reactions ________ ________________________________________________________________________________________________

DRUG USE:Tobacco - # packs/day _______ # years used _______ Alcohol Use - type/amount ______ frequency ___
Recreational Drugs -______________________ frequency _______ IVDA - frequency _______ sharing needles ___

FAMILY HISTORY: ( Illness in family, mother, father, siblings)

____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

SOCIAL HISTORY: Language Spoken __________________ Major loss/change in past year ___________________________
Age: ________ Sex: ________ Marital Status: ________ Developmental Level: ________ Role/Position in Family: ______________________
Family Constellations (#, Ages): _____________________________________________ Support System: ___________________________
Education: ___________________________________ Occupation: __________________________________________
Religious beliefs/practices : _____________________________________________________________________________________________________
Cultural/Ethic Background: _________________________________Pertinent Cultural Practice: ______________________________________________
Living Arrangements ( # rooms, people, adequate heat/hot water, etc.,) ___________________________________________________________________
Health Insurance: __________________________________________________ Financial Concerns: _________________________________________

NUTRITIONAL HISTORY: Special diet/Supplements ______________________ Appetite _______________________

Number of meals/day: _________ Who prepares meals: ___________________________ Food likes/Dislikes: _______________________________
Religious requirements: ____________________________________________________ Eats alone or with others: _____________________________
Dentition/Dentures/Dominant Hand: _____________________________________________________________________________________________
Recent Weight Gain/Loss: ________________ Dysphagia: _____________________ Food Allergies: _______________ Reaction: ______________
Bowel Habits (frequency, consistency of stool, use of laxatives): _______________________________________________________________________
Urinary elimination (frequency, dysuria, complaints): ________________________________________________________________________________

REST/SLEEP/ACTIVITY:
Usual #hrs/night: ________ Naps (time of day/length): ________ Nocturia_________________ Developmental stage Variations ____________________
Use of meds to sleep: ___________ Sleep rituals: _______________________ Hobbies: _______________________ Excercise: ___________________
Need for Assistance with ADL's: _____________________ Bathing: ____________ Toileting: ___________ Dressing: ________ Feeding: _________
Ambulating _________ Transferring ________ Stair Climbing __________ Shopping _______ Cooking _______ Home Maintenance __________________
(S = self, A = assist, T = total care)

DISCHARGE PLANNING:
Lives: Alone _____ With ________________________________________ No known residence _____________________________________________
Intended Destination Post Discharge ______________ Home ___________ Undetermined _____________ Other _______________________________
Previous Utilization of Community Resources:
____ Home care/Hospice ____ Adult day care _____ Church groups ______ Other _____ Meals on Wheels ______ Homemaker/Home health aide
____ Community support group
Post-discharge Transportation: ________ Car ________ Ambulance __________ Bus/Taxi ______ Unable to determine at this time
Anticipated Financial Assistance Post-discharge?: ______ No ______ Yes Anticipated Problems with Self-care Post-discharge?: ______ No ______ Yes
Assistive Devices Needed Post-discharge?: ________ No ________ Yes
Referrals: Discharge coordinator ________ Home Health _________ Social Service _________ V.N.A. ________ Other Comments __________________

TEACHING NEEDS: (Client, Family/Readiness to learn/Barriers to Learning) ________________________________________________________

____________________________________________________________________________________________________________________________
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____________________________________________________________________
DATA COLLECTION PHYSICAL ASSESSMENT
DAY 1 DAY 2

General Appearance

Systemic Assessment - circle/describe

A. Neurological
Mental Status: LOC: alert/drowsy/
lethargic/stuporous/comatose/
restless/confused
Orientation: time/place/person/recent memory
Thought Process: reality/delusions/
hallucinations/attention span
Headaches: Location/frequency
Eyes: glasses/diplopia/pain/discharge/perla
Sclera: red/yellow/clear
Ears: Hearing loss/tinnitus/vertigo/
deformities
Speech: Clear/slurred/coherent
Ability to Swallow:
Gait:
Parasthesia:
Weakness:
Coordination:

B. Cardiovascular
B/P: site/position; Body Temperature & route
Apical Pulse: rate/rhythm/quality
Respirations: rate/labored/unlabored
Pulse oximetry: O2 Sat
Pain: location/frequency/duration/intensity on a
scale of 0 - 10/provokes/palleates/quality/
radiates
fatique/dizziness/chest pain/numbness/
tingling in extremeties
Right Left Right Left
Arterial Pulses Carotid

0 – absent Brachial

1+ - barely palpable
Radial

2+ - decrease Femoral

3+ - full (normal) Popliteal

4+ - bounding Posterior
Tibial

Symmetry Dorsalis pedis

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 PHYSICAL ASSESSMENT
DATA COLLECTION
DAY 1 DAY 2

B. Cardiovascular (continued) TOES FINGERS

Capillary refill (norm less than 3 seconds)
color/temperature/movement/sensation
R R

L L

symmetry symmetry

Homan's Sign ( pain upon dorsiflexion) R L

Skin color/temp/diaphoresis/edema
Cardiac Monitoring:

C. Respiratory Anterior:
Breath Sounds: Describe all auscultated RUL
lung sounds/clear/decreased/absent
Adventitious: rales/rhonci/wheeze LUL
Respiratory rate/rhythm/depth/quality/effort RLL
of breathing/dyspnea/SOB
LLL
Posterior
RUL
LUL
RML
RLL
Cough/Productive (describe sputum)
Non-productive (frequency/precipitation
factors/relief measures)
Chest Symmetry: equal/unequal
Chest tube: location/drainage
Oxygen Therapy:
Mode (type)
Percentage
Liter flow rate
Ventilator
FIO2 TV RR
Ventilator
FIO2 TV RR
CMV, SIMV, CPAP
PEEP
Pressure Support
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DATA COLLECTION PHYSICAL ASSESSMENT
D. Integumentary
DAY 1 DAY 2

Skin:
Color:
pale/cyanotic/flushed/mottled/jaundice
Temperature: warm/cold/moist
Turgor/texture
Mucous Membrane:
Color/moisture/integrity
Rashes/petechiae/ecchymosis/ulcerationss
cars/scaling/flaking/purpura/pruritis/
integrity
Wound: location/approximation/odor,
discharge
Decubitus Ulcers:
location/type/size/shape/stage
Dressings: location/ drainage/ odor

E. Gastrointestinal:
Height/Weight:
Diet/Appetite/Tolerance:
Nausea/Vomiting:
Lips: color/moisture/lumps
Gums & Teeth:
swelling/bleeding/discoloration/retraction/
inflammation/loose/missing or carious teeth
Last Bowel Movement/consistency/color
Continence/diarrhea/constipation
Bowel Sounds: present/ absent, hyper/hypo RUQ LUQ RUQ LUQ
active
RLQ LLQ RLQ LLQ

Abdomen:
soft/distended/tenderness/colostomy
Parenteral Fluids:
IV:
Solution:
Location:
Rate:
Site appearance:

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DATA COLLECTION PHYSICAL ASSESSMENT
E. Gastrointestinal:
Hyperalimentation:
Solution:
Location:
Rate:
Site appearance:
Gavage: (NG, PEG):
Type:
route:
amount:
frequency:
residual:

F. Genitourinary
Continence:
Voiding: frequency/ color/clarity/
odor/amount/dysuria/urgency
Bladder distention:
Vaginal/Penile Drainage:
Catheter: type/patency/drainage/

G. Musculoskeletal
Extremities:
deformities/nodules/atrophy/joint
stability
ROJM: upper lower upper lower

R R R R

L L R R

Muscle Tonus/Strength:

Coordination/Gait/Balance:

Pain/Tenderness/Edema:

Supportive Devices:

Casts/Traction:

H. Endocrine/Reproductive:
Fatigue/wt. change/temperature
intolerance
Hair distribution/ulcers/herpes/warts/
Polydipsia/Polyuria/Polyphagia:
Breast (masses/dimpling/ discharge/
pain)

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 DATA COLLECTION PHYSICAL ASSESSMENT
DAY 1 DAY 2

H. Endocrine/Reproductive:
(continued)

Last Mammogram/results:
LMP/last pap smear & results:
Gravida/Para:
Penis: location of
meatus/chancres/discharge/
tenderness/swelling
Scrotum:
lumps/swelling/ulcers/tenderness/
testicles
Last Prostate exam & results:

TEXTBOOK PICTURE (Definition, Major S/S, Tx)

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DATA COLLECTION: PHYSICIAN ORDERS
Date: ORDERS:

Diet:

Activity:

Lab/Diagnostic Tests:

Treatment/Therapies

Medications:

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 PHARMACOLOGY DATA ANALYSIS
Trade Name Generic Name Classification Normal Dosage Action Side Effects

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DATA COLLECTION: Diagnostic
(document results of admission &
current result & significance) & Lab Tests
Normal: Include normal Admission Current Significance: Circle only the appropriate
parameters for assigned Date Date significant finding or enter the reason if
clinical agency. not printed.

Complete Blood Count

WBC ↑Inflammatory and infectious processes, leukemia.

↓Aplastic anemia, viral infections.

RBC ↑
↓Below NR – indicates anemia, hemorrhage
Hgb ↑COPD, high altitudes, polycythemia.
↓Anemia hemmorhage, overhydration.
Hct ↑Dehydration, high altitudes, polycythemia.
↓Anemia, hemmorhage, overhydration.
MCV ↑Macrocytic anemia
↓Microcytic anemia
MCH ↑Macrocytic anemia
↓Microcytic anemia
MCHC ↑Spherocytosis
↓Hypochromic Anemia
Platelet ↑Acute infections, chronic granulocytic leukemia, chronic
pancreatitis, cirrhosis, collagen disorders, polycythemia,
postsplenectomy
↓Acute leukemia, DIC, thrombocytopenic pupura.
Differential ↑ Acute infections
Band Neutrophils

Esonophils ↑Allergic reactions, esinophilic and chronic granulocitic

leukemia, parasitic disorders, Hodgkin’s disease.
↓Steroid therapy
Basophils ↑Hyperthyroidism, ulcerative colitis, mycloproliferative
diseases
↓Hyperthyroidism, stress
Lymphocytes ↑Chronic infections, lymphocytic leukemia mononucleosis,
viral infections
↓Adrenocortical steroid therapy, whole body irradiation.
Monocytes ↑Chronic inflammatory disorders, malaria, monocytic
leukemia, acute infections, Hodgkins disease.
↓Steroid therapy

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DATA COLLECTION: Diagnostic
(document results of admission &
current result & significance) & Lab Tests
Normal: Include normal Admission Current Significance: Circle only the appropriate
parameters for assigned Date Date significant finding or enter the reason if
clinical agency not printed.

Pt Control ↑ Warfarin therapy, deficiency of factors I, II, V, VII, and X,

vitamin K deficiency, liver disease.
INR
Ptt Control ↑Deficiency of factors, I,II, V, VII, IX and X, XI, <ll;
hemophilia; liver disease, heparin therapy.

Serum Electrolytes ↑Dehydration, impaired renal function, primary

aldosteronism, steroid therapy.
Na
↓Addison’s disease, diabetic ketoacidosis, diuretic therapy,
excessive loss from gastrointestinal tract, excessive
perspiration, water intoxication.

K ↑Addison’s disease, diabetic ketosis, massive tissue

destruction, renal failure.
↓Cushing’s syndrome, severe diarrhea, diuretic therapy,
gastrointestinal fistula, pyloric obstruction, starvation,
vomiting.

Cl ↑Cardiac decompensation, metabolic acidosis, respiratory

alkalosis, steroid therapy, uremia .
↓Addison’s disease, diarrhea, metabolic alkalosis,
respiratory acidosis, vomiting.

BUN ↑Increase in protein catabolism (fever, distress), renal

disease, UTI.
↓Malnutrition, sever liver damage.
Creatinine ↑Active rheumatoid arthritis, biliary obstruction,
hyperthyroidism, renal disorders, severe muscle disease
↓Diabetes Mellitus.

Glucose ↑Acute stress, cerebral lesions, Cushing’s disease,

Diabetes M., hyperthyroidism, pancreatic insufficiency.
↓Addison’s disease, hepatic disease, hypothyroidism,
insulin overdosage, pancreatic tumor, pituitary
hypofunction, postgastrectrectomy dumping syndrome.

CO2 ↑Compensated respiratory acidosis, metabolic alkalosis

↓Compensated respiratory alkalosis, metabolic acidosis
Mg ↑Addison’s disease, hypothyroidism, renal failure
↓ Chronic alcoholism hyperparathyroidism, hyperthyroidism,
hypoparathyroidism, severe malabsorption.

Ca ↑ Acute osteoporosis, hyperparathyroidism, Vitamin D

intoxication, multiple myeloma.
↓ Acute pancreatitis, hypoparathyroidism, liver disease,
malabsorption syndrome, renal failure, Vitamin D
deficiency.

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DATA COLLECTION: Diagnostic
(document results of admission &
current result & significance) & Lab Tests
Normal: Include normal Admission Current Significance: Circle only the appropriate
parameters for assigned Date Date significant finding or enter the reason if
clinical agency not printed

Albumin ↑Dehydration
↓ Chronic liver disease, malabsorption, malnutrition,
nephrotic syndrome, pregnancy

Total Protein ↑Burns, cirrhosis (globulin fraction) dehydration.

↓Congenital agammaglobulinemia, liver disease,

malabsorption

Urinalysis

Color Straw
Specify gravity ↑Albuminuria, dehydration, glycosuria
↓Diabetes insipidus.
Ph ↑Chronic renal failure, compensatory phase of alkalosis,
salicylate intoxication, vegetable diet
↓Compensatory phase of acidosis, dehydration,
emphysema

Glucose (negative) ↑Diabetes M. low renal threshold for glucose resorption,

physiologic stress, pituitary disorders.

Ketones (negative) ↑Marked ketonuria

Blood (negative) ↑Infection in urinary tract/ See RBC
Protein (negative) ↑Congestive heart failure, nephritis, nephrosis, physiologic
stress.

Bile (negative) ↑Hepatitis

Casts (absent) ↑Renal alterations
RBC (negative) ↑Damage to glomerulus or tubules, trauma, disease of
lower urinary tract.

WBC (negative) ↑Infection in urinary tract

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DATA COLLECTION: Diagnostic
(document results of admission &
current result & significance) & Lab Tests
Admission Current Significance: Circle only the appropriate
Date Date significant finding or enter the reason if
not printed.

EKG

Chest X-ray

Arterial Blood Gases

ph (7.35 – 7.45)

pCO2 (35 - 45)

pO2 (80 - 100)

HCO 3 (22 – 26)

o2sat (90 – 100)

Other tests/procedures related to

client hospitalization (include
normal, client results and
significance).

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 DATA ANALYSIS: NURSING DIAGNOSIS
DATA SOURCE SIGNIFICANT FINDINGS NURSING DX: Write all applicable in PES format.
1. Nursing History

2. Physical Assessment

3. Diagnostic/Lab Assessment

4. Physician's Orders

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Student _____________________________________________ Date(s) Experience _____________________
Client's Initials_________________________________________

NURSING CARE PLAN

Nursing Diagnosis Expected Outcome & Nursing Actions Rationale Evaluation of Outcome
Criteria for Measuring
Problem:

Etiology (related to)

Signs & Symptoms

(as evidence by)

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Student _____________________________________________ Date(s) Experience _____________________
Client's Initials_________________________________________

NURSING CARE PLAN

Nursing Diagnosis Expected Outcome & Nursing Actions Rationale Evaluation of Outcome
Criteria for Measuring
Problem:

Etiology (related to)

Signs & Symptoms

(as evidence by)

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Student _____________________________________________ Date(s) Experience _____________________
Client's Initials_________________________________________

NURSING CARE PLAN

Nursing Diagnosis Expected Outcome & Nursing Actions Rationale Evaluation of Outcome
Criteria for Measuring
Problem:

Etiology (related to)

Signs & Symptoms

(as evidence by)

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Student _____________________________________________ Date(s) Experience _____________________
Client's Initials_________________________________________

NURSING CARE PLAN

Nursing Diagnosis Expected Outcome & Nursing Actions Rationale Evaluation of Outcome
Criteria for Measuring
Problem:

Etiology (related to)

Signs & Symptoms

(as evidence by)

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Student _____________________________________________ Date(s) Experience _____________________
Client's Initials_________________________________________

NURSING CARE PLAN

Nursing Diagnosis Expected Outcome & Nursing Actions Rationale Evaluation of Outcome
Criteria for Measuring
Problem:

Etiology (related to)

Signs & Symptoms

(as evidence by)

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Student's Nurse’s Progress Note Day 1 Student's Nurse’s Progress Note Day 2

Spring ‘06
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 NAME ___________________________
COURSE _________________________
SEMESTER _______________________

STUDENT SELF-EVALUATION

Directions: Take time to do a realistic evaluation of your abilities in the areas listed below. Reflect on your overall
performance for the course. What can you identify as support/barriers to your performance. Cite specific
examples from your clinical experiences.

1. NURSING PROCESS:

A. Assessment –

What was your ability to gather data? Did you assess the client’s cultural, developmental, emotional, physical,
psychological, and spiritual needs? Did you use all sources ex. client, family, staff, medical record etc.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

B. Analysis/Diagnosis -

Did you identify significant findings and cluster the data to arrive at diagnosis? Did you use your Nursing Diagnosis
book to select the diagnostic label? Did you identify contributing/risk factors for your patient? Did you use the PES
format?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

C. Planning –

Did you prioritize your diagnoses? Were outcomes stated with specific criteria for measurement? Were nursing actions
clear, did you include patient medications and teaching needs?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

D. Implementation –

Did you carry out the plan, maintain a safe environment, provide patient/family teaching, collaborate with others?

_____________________________________________________________________________

_____________________________________________________________________________

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 E. Evaluation –

Were the outcomes met, how? Did you state specific outcome criteria? Does the plan need to be continued or
changed?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
2. THERAPEUTIC INTERVENTIONS

What psychomotor skills did you perform? What do you need improvement with? What skills would you like to perform?

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________________________

3. COMMUNICATION ABILITIES

Did you use therapeutic techniques? How effective was your verbal/non-verbal communication with the client/family, staff, peers,
instructor? How would you describe your participation and contributions to pre and post conference? Was your written
documentation organized clear, concise and complete? Did you complete the flow sheet, I & O, Medex etc?

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________________________

4. MANAGEMENT

Did you manage your time well? Was all care given? Were your priorities correct?

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________________________

5. CRITICAL THINKING

Did you apply theoretical knowledge? Can you explain and support the thinking behind the actions you chose? Did you
consider . . . What if something goes wrong? or What if we try . . . ? Did you recognize your biases? What would you do
differently? Did you have self-confidence? Did you demonstrate good clinical judgement?

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________________________

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 NURSING ASSESSMENT AND CARE PLAN EVALUATION CRITERIA
Please note: All elements of the nursing process must be completed in order to receive a satisfactory grade of 75.

ASSESSMENT (20)

Data is logically summarized:

a) History and Health Assessment 4
b) Physical Assessment 4
c) Physician’s Orders 2
d) Textbook Picture 2
e) Pharmacology Data Analysis 4
f) Diagnostic and lab tests 4

DIAGNOSING (DATA ANALYSIS) (25)

Clusters Data 5
Identifies ALL Significant Findings 10
Identifies ALL relevant nursing diagnoses using the PES format 10

PLANNING (Develops Plan for 4 highest priority diagnoses – 3 physiological/1 psychological) (15)

Prioritizes all identified diagnoses as HI-MED-LOW 5

Identifies appropriate client goals/desired outcomes 5
States criteria for evaluation of client goals/outcomes 5

IMPLEMENTATION (30)

Identifies independent interventions to accomplish the top priorities for care 7

(including teaching when appropriate)
Identifies interdependent interventions to accomplish the top priorities of care 7
(including medications when appropriate)
Cites references for interventions 2
Explains scientific rationale for each intervention 7
Documents nursing activities on appropriate flow sheets and nurses’ notes 7

EVALUATION (10)

Evaluates outcomes for 4 top priority diagnoses using 5

stated criteria for evaluation
Evaluates (self) performance of care 1
Correct grammar is used throughout document 2
Paper is legible 2
Total Points possible 100

Rev: Spring 2006

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