Nursing Assessment Form Student Name:Course:Nursing 219 Instructor: Patient Initials:LHMale/FemalePatient Age:68DOB:04/25/1952 General Information:Chief Complaint:Dehydration and Hyperkalemia; pain in right ankle and joints of right foot; open wound r ankle Has patient been in the hospital or other health facility in the past six months? Yes / No If yes to above, what was the nature of the problem? Vital Signs: Temperature: 97.4Source: OralPulse:73Source:Machine Respirations: 18Oxygen Saturation:98Room Air / Supplemental Oxygen at Blood Pressure: 131/63Lying /Sitting / Standing Source:Machine Height (inches): 5’7” Actual /StatedWeight (lbs): 203Actual /Stated Allergies:(Include medications and food and reaction)Codeine Medical History: Previous Medical Diagnosis:Cirrhosis of liver (nonalcoholic steatohepatitis), COPD, coronary arteriosclerosis, disorder of thyroid gland, H/O: diabetes mellitus Previous Surgical History:Broken and surgery right ankle Medications taken at home (include prescribed, OTC, herbals or natural remedies, and/or vitamin or minerals)! Name (generic if possible)DoseReason patient is taking See Med Sheet Does patient have any issues with paying medication or taking medication? Yes /No(Elaborate if needed) Said she has the medical card and it has so far covered everything. Does pt: SmokeYes /No if yes, # of PPDDoes pt use Alcohol: NoneDoes pt use other drugs:None Please check all immunization the patient has had in the past year: FluPneumoniaTetanusOther: () Religious Affiliation and Requests: Fall Risk Score (results from scale):25Is Patient at risk for falls:Yes/No
