Physical Nursing Assessment Report

753 Words 4 Pages
Database and Assessment
Table 1 – Physical Nursing Assessment Data
GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg.

SKIN/HAIR/NAILS:
Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain. Mucous membranes are moist. Fingernails trimmed and clean. Toenails were thick and had a yellowish color to them. Eyebrows full and symmetric. Patient has mostly gray, thinning hair. Patient had small amount of hair on arms, legs, and in axial and pubic areas.
Risk for skin breakdown

FACE/HEAD/NECK (Eyes/Ears/Nose/Mouth/Throat):
Symmetrical facial structures.
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Blood glucose was 86mg/dL

Table 2 – Functional Health Patterns Data
NUTRITION METABOLIC (diet, examples of daily food/fluid intake, food preferences, appetite):
Patient on a Cardiac/heart healthy diet. States “the food here is very good” but does not eat an adequate amount. Patient was able to eat on his own.

ELIMINATION (normal bowel/bladder function, aides):
Patient has an indwelling Foley catheter. Continent of bowel habits both at home and at the hospital.

ACTIVITY-EXERCISE (ADL’s, leisure, amount/type of exercise):
Patient seems very fatigues and does not get up out of bed much. Patient watched television most of the day but would periodically fall asleep. Patient worked well with physical therapy and was able to stand up well, take a few steps and sit on the chair. After about 15 minutes of sitting on the chair, patient heart rate dropped to 72, so we moved him back to bed. Patient requested that he feed himself after I tried feeding him and he did very well.

SLEEP-REST (aides):
Patient reports being able to sleep through the night well. Reports fatigue and frequent napping throughout the day while at the hospital.

HEALTH PERCEPTION-HEALTH MANAGEMENT
(include alcohol, drug, tobacco use, compliance with

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