Question

Client Assessment Form

COMPLETE STEP 2, 3 AND 4

(If an area has significant abnormal findings, a more focused assessment is required)

Date of admission:

Date of assessment:

Gender Identification: Male

Allergies: Penicillin

Admitting Diagnosis:

­­­onset of agitation and confusion from past 48 hours

Past Medical History (diagnosis and date of diagnosis if possible)

Benign prostatic hyperplasia, Hypertension and osteoarthritis

Past Surgical history (diagnosis and date of diagnosis if possible)

N/A

Medication Summary – add additional sheets if necessary, include scheduled meds and PRN meds

Medication	Dose	Route	Frequency	Reason YOUR patient is taking
NS	500 CC	IV	30ml/hr

Vital Signs

Temp

HR

BP

RR

O2 Sat on R/A or amount of O2

MOBILTIY: BED RIDDEN

NEUROLOGICAL:

ALERT AND DISORIENTED, GCS-13,do not follow simple instructions, confused speech with agitated behavoir, stomach is soft but tender upon palpation, Foley’s catheter from 1 month due to urinary retention, dark, amber and pus is visible in urine, dry mouth and tongue, bruises, lesions and sign of skin breakdown and the result of the urine analysis is secondary BPH.

Step 2: List abnormal assessment data together that is linked

Step 3 Identify the nursing problem go back to the above cluster sets and put a ‘name’ to the problem

Step 4:STEP 4 - Prioritize each Nursing Problem – go back to the cluster sets and beside each problem, rank the problems from most urgent (#1) to least urgent (#4)

38.7

104

110/60

24

92%

Answer 1

Abnormal assessment data

• GCS score of 13 indicates as mild Traumatic Brain Injury (TBI)
• Disoriented
• Not following instructions
• Slurred speech
• Catheter is inserted due to urine retention
• Dark and amber coloured urine
• Presence of puss
• Dry mouth and tongue
• Bruise and lesions

Step 3

diagnosis - Mild traumatic brain injury

STEP 4

1. GCS score of 13 is a potentially risky situation that need to assessed immediately
2. Dehydration must be treated by providing plenty of fluids in order to ensure the patient is hydrated ,Improve urine output
3. Bruise and lesions are to be considered
4. Provide a calm and relaxed atmosphere for the patient to relax hence patient can gain consiousness eventually.