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Fields
Nursing Assessment
Patient Name
First Name
Last Name
Temperature
Temperature Type
Oral
Rectal
Axilla
Pulse: Apical
Pulse: Radial
Respirations
Blood Pressure
Blood Pressure Location
Left Arm
Right Arm
Blood Pressure Taken
Lying
Sitting
Standing
Lung Sounds
Present and clear all lobes
SOB at rest
SOB on exertion
Lung Condition
Wheezes
Rales
Rhonchi
Nonproductive cough
Productive Cough-
Tracheostomy
Cigarette Packs smoked/day
Anterior RLL
Anterior RLL
Anterior LUL
Anterior LLL
Posterior RUL
Posterior RLL
Posterior LUL
Posterior LLL
Oxygen
Yes
No
Oxygen liters/minute
Oxygen liters/minute via
Nasal Cannula
Face mask
Continuous
PRN
Cardiac
Asymptomatic
Pacemaker
Orthopnea
Palpitations
Chest Pain
Yes
No
Chest Pain: Location, Severity, and Duration
Chest Pain: Comments
Mental Status
Yes
Alert
Oriented to person
Oriented to place
Oriented to time
Unresponsive
Confused
Forgetful
Present Behavior
Cooperative
Anxious
Withdrawn
Depressed
Other:
Other Value
Communicates in English
Yes
No
If does not communicate in English, specify language & methods of communication
Speech abnormalities?
Aphasia
Slurring
Other:
Other Value
S/S Potential abuse or neglect
Yes
No
Ambulation/Mobility
Independent
Supervision
Contact Guard
Assist
Walker
Cane
Crutches
Transfers with assist/contact guard
Transfers with Hoyer Lift
Wheelchair
Bed Bound
Musculoskeletal
No Problem
Generalized weakness
Weak
Stooped posture
Poor balance
Amputation
Prosthesis
Joint pain
Joint stiffness
Joint swelling
Contractures
Musculoskeletal: If Weak, Amputation, or Contractures, explain
Neurological
Asymptomatic
Vertigo
Dizziness
Headache
Seizure
Tremors
Prosthesis
Joint pain
Eyes
No Problem
Glasses
Legally blind
Blurred vision
Cataracts
PERL
Ears
No Problem
Hard of Hearing
Hearing Aid
Tinnitus
Right Ear
Left Ear
Nose
No Problem
Drainage
Mouth
No Problem
Full dentures
Partial Dentures
Dentures don’t fit properly
Poor dentition
Pain
Denies any present or recent pain, no nonverbal signs of pain, not at risk for pain relative to diagnosis
Pain Scale
0=No Pain - 10=Most severe pain
Currently in pain?
No
Yes
Location of pain
Type of Pain
Sharp
Burning
Dull
Cramping
Other:
Other Value
Responds to
RX
Other
If Other, please specify
Patient Name
First Name
Last Name
Nutrition: Current diet
Regular
Kosher
2 Gm Na+
Low Fat
Low Cholesterol
Other:
Other Value
Nutrition: Diet Plan
Knowledgeable re diet
Needs diet instruction
Food Allergy
1800 Calorie ADA
N/A
Height
Weight
Appetite
Good
Fair
Poor
Weight Gain/Loss
Significant weight gain in past 3 months
Significant weight loss in past 3 months
Fluid Intake
Adequate
Inadequate
Restricted
Fluid Intake Restricted
/day
Nutrition Risk Assessment (mark all that apply)
Difficulty chewing or swallowing
Loss of appetite
Inability to feed self
Appears significantly overweight □ Obese
Appears significantly underweight
Does not always have enough money to buy food
Alcohol or drug abuse
Chronic disease
Altered mental status
Is not always able to shop or cook and no one is able to help
ADL needs assistance with:
Ambulation
Transfers
Turn and Position
Safety
Housework
Shopping
Laundry
Meal Preparation
Feeding
Dressing
Toilet
Diapers/Incontinence Care
Shower
Bed bath
Skincare
Remind Medications
Other:
Other Value
DME/ supplies in home in good condition?
Yes
No
DME supplies needed
Follow up for DME/Supplies
Skin
Intact
Poor turgor
Generalized dryness
Color- Normal
Pallor
Cyanosis
Bruising, wound, rash or lesion (see diagram)
RN Signature
[clear]
Use your mouse or finger to draw your signature above
Date of visit
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
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