please answer this form up on case patient diagnosed with ( cerebrovascular accident, “CVA”

no need for actual patient ” 

Student Name:

Student ID:

Date:

Instructor Name:

Allotted Grade:

Given Grade:

ILOs #: 1.2

Differentiate normal physical findings and variations in health to identify client health problems.

ILOs #: 2.1

Critically analyze health assessment findings, including diagnostic data for health priorities and consider actual health problems.

ILOs #: 2.3

Utilize a holistic approach to assess clients with emphasis on environment and family structure and functioning

ILOs #: 2.4

Assess the physiological, psychological, developmental and sociocultural factors that directly and indirectly affect individuals’ health.

ILOs #: 3.2

Commit ethical and legal principles in conducting and reporting findings relevant to health assessment

I. Patient Profile
(2 marks):

Patient’s Name:

Gender:

Age:

Birth date/ place:

Marital Status:

Address:

Religion:

Nationality:

Source of Data:

Date: 

II. Chief complaint/ Reason for seeking care (CC) (Reason for the encounter/seeking medical help
) (5 marks):
(One or more major symptoms + their last occurrence)

III. History of Present Illness
(10 marks):

(State the chronological sequence of events in reference to the client’s chief complaints applying PQRSTU)

First Major Symptom

P (Palliative & Provocative):

Provocative: What can increase the symptom? What brings it on? What were you doing when you first noticed it? What makes it worse?

Palliative: What can decrease the symptom? What makes it better?

Q (Quality): How can you describe the symptom? How does it look, feel, sound?

R (Region & Radiation):

Region/ where has the symptom occurred on your body:

Radiation/ does it radiate to other parts of the body. If yes, where:

S (Severity):  How intense/severe is it? how much severe is your symptom, on a scale of 1-10, with 10 being the most severe? is it getting better, worse, staying the same?

T: Timing

Onset: When did the pain or symptom start? Exactly when did it first occur?

Duration: How long did it last?

Frequency: How many times a day does it happen? How often does it occur?

U (Understand Patient’s Perception of the problem): What do you think it means?

A (Associated factors): was the symptom associated with other symptoms)

Second Major Symptom

P (Palliative & Provocative):

Provocative: What can increase the symptom? What brings it on? What were you doing when you first noticed it? What makes it worse?

Palliative: What can decrease the symptom? What makes it better?

Q (Quality): How can you describe the symptom? How does it look, feel, sound?

R (Region & Radiation):

Region/ where has the symptom occurred on your body:

Radiation/ does it radiate to other parts of the body. If yes, where:

S (Severity):  How intense/severe is it? how much severe is your symptom, on a scale of 1-10, with 10 being the most severe? is it getting better, worse, staying the same?

T: Timing

Onset: When did the pain or symptom start? Exactly when did it first occur?

Duration: How long did it last?

Frequency: How many times a day does it happen? How often does it occur?

U (Understand Patient’s Perception of the problem): What do you think it means?

A (Associated factors): was the symptom associated with other symptoms)

IV. Past Health History
(5 marks):

Childhood illnesses: (include name of disease, age and treatment received)

Health Maintenance:

Immunizations: (include name of vaccination, number of doses, age when administered, dosage lessened or given fully, causes if not given)

Previous Screening Tests: (include test name, result and when they were last performed)

Accidents or Injuries: (Include cause, date and treatment)

Adult Illness:

Serious or Chronic Illnesses: (Include name of the disease, duration and related treatments)

Surgical operations: (Include dates, indications, and types of operations)

Pervious hospitalization: (Include cause, name of hospital, how the condition was treated, how long the person was hospitalized, and name of the physician)

Obstetric/Gynecologic:
(Include obstetric history, menstrual history, methods of contraception, sexual function number of pregnancies (gravidity), number of deliveries in which the fetus reached full term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). For each complete pregnancy, note the course of pregnancy; labor and delivery; sex, weight, and condition of each infant; and postpartum course)

Psychiatric: (Include Illness and time frame, diagnoses, hospitalizations, and treatments)

Allergies: (Include allergen type (medication, food, or contact agent such as fabric or environmental agent), and the reaction)

V. Functional Assessment
(15 marks):

Self-Esteem, Self-Concept:

Education level: (last year of schooling/ last grade completed) & Other significant training)

Financial status: (Monthly income, income adequate for lifestyle and/or health concerns)

Value-belief system: (religious practices and perception of personal strengths)

Activity/Exercise: A daily profile reflecting usual daily activities. “Tell me how you spend a typical day.” 

Ability to perform ADLs: (independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs)

Is there any use of wheelchair, prostheses, or mobility aids?

Leisure activities enjoyed and the exercise pattern: (type, frequency and duration per day or week, method of warm-up session, method of monitoring the response of the body to exercise).

Sleep/Rest: (Sleep patterns (hours of sleep and arising), daytime naps, any sleep aids used)

Nutrition/Elimination. Recall of all food and beverages taken over the past 24 hours. Ask, “Is that menu typical of most days?” 

Dietary Consideration (Food preferred/like to eat):

Dietary Restrictions (Food dislike or not allowed to eat):

Any food allergy or intolerance:

Daily intake of caffeine (coffee, tea, cola drinks):

Regularity of stools and urination/ how many times a day:

Problems with mobility or transfer in toileting, continence, use of laxatives:

Interpersonal Relationships/Resources:

Primary Care Provider:

Current house-hold:

Social roles: “How would you describe your role in the family? How would you say you get along with family, friends, and co-workers?” 

Support systems: “To whom could you go for support with a problem at work, your health, or a personal problem?”

Contact with others: “Is time spent alone pleasurable and relaxing, or is it isolating?”

Spiritual Resources:

Use the Faith, Influence, Community, and Address (FICA) questions

Faith: “Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?”

Influence: “How does your religious faith or spirituality influence the way you think about your health or care for yourself?”

Community: “Are you a part of any religious or spiritual community or congregation?”

Address: “Would you like me to address any religious or spiritual issues or concerns with you?”

Coping and Stress Management:

Is there any change in lifestyle or any current stress?

What methods you have tried to relieve stress and whether these have been helpful?

Personal Habits:

Tobacco: “Do you smoke cigarettes (pipe, use chewing tobacco)? At what age did you start? How many packs do you smoke per day? How many years have you smoked?” “Have you ever tried to quit?” and “How did it go?”

Alcohol: Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test

Illicit or Street Drugs: prescription painkillers, frequency of use and how use has affected work or family.

Environment/Hazards:

Housing and neighborhood (living alone, knowledge of neighbors):

Any hazards in workplace and at home

Use of seatbelts:

Travel or residence in other countries, including time spent abroad:

Occupational Health:

Occupation: What is your job?

Exposure History: Ever worked with any health hazard such as asbestos, inhalants, chemicals, repetitive motion? 

Wear any protective equipment? Any work programs in place that monitor exposure? Aware of any health problems now that may be related to work exposure?

What do you like or dislike about the job?

VI. Perception of Health
(3 Marks)

“How do you define health?       

How do you view your situation now?

What are your concerns?

What do you think will happen in the future?

What are your health goals?

What do you expect from us as nurses, physicians (or other health care providers)?”

VII. Family History
(5 marks):

Used primarily to discover any hereditary or familial diseases in the family members
Diagram the age and health, or age and cause of death, of each immediate relative including parents, grandparents, siblings, children, and grandchildren.
Ask specifically about coronary heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis (TB).

VIII. Review of Body Systems
(10 marks): (see guidelines for more details)

Describe abnormalities for general and affected System/s:

IX. Physical Examination:
(20 Marks)

General Survey:

Baseline Vital Signs (2%)

Temperature

Blood Pressure

Pulse

O2 Saturation:

Respiration

Skin:

Head, Eyes, Ears, Nose, Throat (HEENT):

Neck:

Thorax and Lungs:

Cardiovascular System:

Abdomen:

Peripheral vascular system:

Musculoskeletal System:

Nervous system:

X. Diagnostic Procedures (Laboratory, Radiologic Imaging Studies, etc.)
(5 marks)
:

Test or Procedure

Date

Results

Interpretations

Rationale for the results

XI. Descriptive and non-descriptive medications
(5 marks)
:

Current medications (Prescribed by physician/doctor):

Generic Name & /

Classification

Trade Name

Dosage

Frequency

Route

Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):

Generic Name & /

Classification

Trade Name

Frequency

Route

Rationale

XII. Interpretation of data and identification of client’s strengths and weaknesses
(5 marks)
:

Strengths

Weaknesses

·

XIII. Nursing Diagnosis
(5 marks)
: 

1

2

3

For Instructor Use Only

Evaluator Name:

Evaluator Signature

Checked by:

Auditor Signature:

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Accredited BSN Program by AHPGS on February 15, 2018