Nursing assessment

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Nursing assessment tool
The written holistic profile should include the following information:
Family and given name: Jones Alexander (please use pseudonym)
Age: 85years Gender: Female
Cultural identity: NZ European Religion: Atheist
Citizenship: New Zealander Family: Lives with husband, Son (live next door to residential unit)
Occupation: Retired ward clerk
Health history: Diabetes Type 2 (diagnosed in 2012)
Reason for admission: Infected wound Right foot toe (Diabetic foot), high blood sugar levels > baseline range for patient
Medical diagnosis: Diabetic foot infection
Allergies: Nil known allergies
Current medications: Paracetamol 1g qid, Amoxicillin 500mg TDS, Injection Insulin Lantus 10 units nocte after meals (only commenced during hospital admission), usually on Metformin 500mg TDS, Injection Humalog prn TDS if BSL>12 prior to meals
Other: Developed small infection while cutting her own ingrown toe nail last month. (March, 2020).
Assessment
Comments/Problems/Needs
Maintaining a safe environment
Patient in four bedded room. Bed is at lowest setting with call bell within reach. Bed space free from clutter.
Communication Language spoken Speech
Well spoken, native fluent English. Speech is clear and articulate.
Breathing and circulation Breathing Skin colour, cough, sputum Smoking history Respiratory rate Circulation Skin colour, chest pain Blood pressure and pulse rate Peripheral circulation Colour, warmth, sensation
RR-20 Breaths/min, nil chest pain on inspiration, nil cough or audible wheeze noted
Non- smoker, never smoked 0 pack history
Pulse rate at radial site 110 beats/min strong and regular pattern. Skin pink and intact Wound on Right foot toe-wound dressing intact. On removal of dressing, yellow wound discharge present.
BP 110/69 mm of Hg
All extremities warm, pink in colour and sensations intact except Right foot-cold to touch and loss of sensation in the base of foot, appearing pink in colour. Capillary refill <2 secs in all extremities.
Nutrition – eating and drinking Recent weight loss or gain Appetite Food preferences/dislikes Eating difficulties/assistance Fluids – intake/preferences Drinking difficulties/assistance
No recent weight changes (baseline weight on admission 60 Kgs)
Appetite reported to be normal, eats meals three times a day, snack (rice crackers and black tea) at bedtime
Prefers food….. Independent with oral intake
Elimination Micturition pattern Night/day Continence Defecation pattern Regularity Continence Aids required – diet, medications
Normal micturition and defecation pattern. Usually bowels open once a day. Nil burning/change in frequency or voiding pattern noted. Nil aids required.
Personal cleansing and dressing Bath/shower Teeth: own, dentures Hair, nails Skin: integrity Appearance of fingers and toes
Independent with personal hygiene-nil assistance required. Dentures-top and bottom, brushes every night. Nails intact-no discolouration or signs of infection apart from R foot toe Skin intact/ dry and scaly on extremities, self-applying personal moisturiser. Wound dressing R foot toe
Controlling body temperature Signs of infection Body temperature
Temperature at the time of this assessment was 37.8 degrees Celsius. Infection present R foot toe/treated-yellowish discharge ooze noted in the dressing at wound, on oral Antibiotics.
Mobilising Balance: sitting, standing, dressing Transferring, walking Aids/prosthesis used Falls risk assessment Dependence/independence
Independent with mobility-uses walking stick.
Falls risk score (High Falls risk score due to factors-Age, using mobility aid, Pain Right foot, absence of sensation on foot)
Working and playing Support systems – family, friends, whänau, pets Work/study Interests, activities: physical, social, intellectual, religious practices/beliefs
Son live next door to unit, visit mother every day. Helps with shopping and gardening. Likes gardening and knitting for grand children in free time
Expressing sexuality Grooming requirements Concerns expressed
Independent with grooming requirements. Likes to have a shower early in morning and put her favourite perfume and makeup on.
Sleeping Hours of sleep, day, night Bedtime – number of pillows Aids to sleep – drink, medications, positioning
Sleeping 6 hour per night whilst in hospital. At home she sleeps for 8 hours. Sleep disrupted in hospital by night nurses checking vital signs
Dying Perception of illness Concerns expressed by family, patient Resuscitation status
Very concerned that worsening of infection will mean wound dressings for longer, want to keep her independence and does not want to become a burden on the family
Mental Status/Cognition Perception of health status Alert/orientated to time and place Memory
Alert and orientated to time, place and person. Short term/Long term memory intact as evidenced by answering questions about ……………
Emotional status Calm/anxious/agitated
Frustrated due to apparent lack of progress in condition. Been in hospital for 2 weeks now.
Special senses Vision – spectacles, prosthesis Hearing – aids
Wears reading glasses, no hearing aids
Pain Assessment tool Location, intensity, duration Pharmacological and non-pharmacological relieving factors
Pain score mostly is 6 out of ten when mobilising. (pain scale 0= no pain and 10= severe pain) The pain feels like sharp/stabbing, radiates up his right toe only when walking. Managed with Paracetamol 4 times a day. Elevating Right leg on one pillow helps
Care Plan Template
Nursing diagnosis
Patient Goal
Nursing intervention
Rationale for intervention
Evaluation of goal

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