Module #1

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General status, vital signs, pain and nutrition Subjective data

Student Name________________

(No patient names or initials allowed).

Submit using Word, with a .doc or .dox suffix; do not use .odt because the forms cannot be graded in that format—this goes for the assignments in all the upcoming weeks for this class.

NOTE: YOU MAY NOT USE A PATIENT FROM YOUR WORKPLACE FOR THIS ASSESSMENT. WE DO NOT WANT YOU TO VIOLATE HIPAA!

Questions

 

 Findings
Current Status  
1. Allergies  
2. Present health concerns

 

  
3. Current medications (prescribed and over-the-counter)  
4. Immunizations  
Past History  
5. Medical  
6. Surgical  
7. Hospitalizations  
8. Injuries  
Family History  
9. List family medical concerns for 3 generations  
   
Pain (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)
10. Pain (using COLDSPA)

 

Character: how does it feel—what sort of pain is it?

 

 

  

 

 

 

 

 
 

11. Onset:

 

  
 

12. Location:

 

  
 

 

13. Duration:

 

 

  
 

14. Severity (scale of 1 – 10):

 

  
 

 

15. Pattern—what makes it better or worse:

 

  
 

16. Associated factors—does it cause you to have other symptoms too?

 

 

  
18. How does pain impact the other areas of life? 2. What are your concerns about the pain’s effect on

a. general activity?

b. mood/emotions?

c. concentration?

d. physical ability?

e. work?

f. relations with other people?

g. sleep?

h. appetite?

i. enjoyment of life?

 
Lifestyle and Health Practices  
What types of recreation or physical exercise?  
Duration of exercise periods, how many times per week?  
Stress: Rate overall life stress on a scale of 1 – 10 (1 being least, 10 most). What are the greatest sources of stress?  
Methods of coping with stress?  
Use of tobacco, alcohol, recreational drugs  
Sleep—typical hours per night  

 

Objective data (General status and vital signs, pain and nutrition)

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission.

Questions

 

 Findings
Current Status  
1. Observe physical development (i.e., appears to be chronologic age).

 

  
2. Observe skin (i.e., general overall color, color variation, and condition).

 

  
3. Observe dress (occasion and weather appropriate).

 

  
4. Observe hygiene (cleanliness, odor, grooming).

 

  
5. Observe posture (i.e., erect and comfortable) and gait (i.e.,rhythmic and coordinated).

 

  
6. Observe general body build (muscle mass and fat distribution).

 

  
7. Observe consciousness level (alertness, orientation, appropriateness).

 

  
8. Observe comfort level-does patient exhibit visible signs of pain?

 

  
9. Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness).

 

  
10. Observe facial expression (culture-appropriate eye contact and facial expression).

 

  
11. Observe speech (pattern and style).

 

  
Vital Signs  
12. Temperature (document route)  
13. Heart rate (pulse– rhythm, amplitude)

(Document units—beats per minute)

  
14. Respirations (rate, rhythm, and depth).

(Document units—breaths per minute)

  
15. Blood pressure  
   

 

 

 

 

Nutritional assessment: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

 

 Findings
Current Status  
1. Type of diet (for instance, low carb, vegetarian, diabetic, etc.)  
2. Appetite changes  
3. Weight changes in last 6 months?  
4. Problems with indigestion, heartburn, bloating, gas?  
5. Constipation or diarrhea?  
6. Dental problems?  
7. Conditions/diseases affecting intake or absorption, i.e., irritable bowel disease, gluten sensitivities, etc.,?  
8. Frequency of dieting?  
Family History  
9. Chronic diseases?  
10. Weight issues?  
Lifestyle and Health Practices  
11. Average daily food intake—how many meals and snacks?  
12. Approximately how many 8-oz. glasses of fluid per day are consumed?  
13. Type of beverages consumed?

 

  
14. Dine alone or with others?  
15. Frequency of eating out?  
16. Do long work hours affect diet?  
17. Sufficient income for food?  
18. Is a specific diet plan used? List a 24 hour recall of food intake.  

 

Objective data: Nutrition assessment

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

 

 Findings
Current Status  
1. Measure height.  
2. Measure weight (1 kg = 2.205 lb).  
3. Determine body mass index (BMI = weight in kilograms/height in meters squared or use the NIH website: http//nhlbisupport.com/bmi/bmicalc.htm). Compare results to BMI in Table 13-3, on in the textbook. To which category does your assessment partner belong? BMI:

 

Category:
4. Measure waist circumference and compare findings to Table 13-5 in the textbook. Which category of risk captures this person’s situation? Waist circumference:

 

Risk category:
   

SBAR

Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from the “General Status, Pain, Nutrition and Vital Signs” assessment would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she gets insufficient exercise, is obese, or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as recommended. Most people don’t drink enough water—you can often use that if nothing more serious is apparent. If your assessment partner has chronic health problems or pain, address one of those problems below.

SBAR  
Situation

(What is the most important problem you have identified? When did it start, and how severe is it?)

 

  
Background

(The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.)

  
Assessment

(What do you think the problem is—which direction does it seem to be going?)

  
Recommendation

(What needs to happen next?)

  

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

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