Module 1,2,3
10
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 | |
| |
| |
| |
| |
Past History | |
| |
| |
| |
| |
Family History | |
| |
| |
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.) |
Character: how does it feel—what sort of pain is it? | |
| |
| |
| |
| |
| |
| |
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 | |
| |
| |
| |
| |
| |
| |
| |
| |
| |
10. Observe facial expression (culture-appropriate eye contact and facial expression). | |
11. Observe speech (pattern and style). | |
Vital Signs | |
| |
(Document units—beats per minute) | |
(Document units—breaths per minute) | |
| |
| |
Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions | Findings |
Current Status | |
| |
| |
| |
| |
| |
| |
| |
| |
Family History | |
| |
| |
Lifestyle and Health Practices | |
| |
| |
| |
| |
| |
| |
| |
| |
Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions | Findings |
Current Status | |
| |
| |
| BMI: Category: |
| 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.