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 |
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