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Diagnosis: Cerebral infraction to unspecified occlusion, Gastrointestinal hemorrhage unspecified, Type 2 diabetes nephropathy, hypertension, obstructive sleep apnea, cognitive communication and muscle weakness. Medication: Insulin aspart ( Insulin aspart 100unit/ml injectable solution), Linagliptin ( linagliptin 5mg oral tablet), Duloxetine 30mg oral delayed release capsule), apixaban 2.5mg oral tablet), amlodipine ( Norvasc 10mg oral tablet), metformin 750 mg oral tablet, extended release)NUR 1020: Foundation of Nursing Practice PRINCE GEORGE’S COMMUNITY COLLEGE DEPARTMENT OF NURSING NUR 1020 CLIENT PROFILE AND ASSESSMENT SCORING CRITERIA Scoring Code Key Student Name: _________________________ S – Satisfactory LD Section: _________________________ NI – Needs Improvement U – Unsatisfactory Please submit this scoring criterion with the Assessment Tool. Area to be scored Scoring code 1. Health History by Review of Systems a. Subjective data is accurate and complete b. No blank areas (none or client denies problems annotated where applicable) 2. Family Health History a. Significant family medical data is accurate and complete b. Familial relationship to client is clearly identified c. Only pertinent medical history associated with 1st and 2nd generation family members is annotated 3. Human Dimensions a. All dimensions (A – G) are assessed. b. Each dimension is assessed accurately and completely 4. Source and reliability of information is annotated 5. Client/Family Learning Needs Identified 6. Diagnostic Tests & Laboratory Data a. Results of diagnostic tests / procedures are given b. Interpretations of abnormal lab values are accurate 7. Physical Examination a. Objective data is accurate and complete 8. Health-Illness Continuum a. Based on previous subjective and objective data, the client is accurately positioned on the continuum b. Rationale for placement on health-illness continuum is clear and accurate. 9. Risk Assessments are completed 10. Discharge Planning Needs are identified accurately 11. Nursing Diagnoses are accurate, appropriate, and based on assessment data a. Nursing Diagnosis are prioritized accurately b. Nursing diagnoses include all 3 components (dx/rt/aeb) 11. Medications a. Classification and sub-classification stated b. Actions of medications are specific & purpose is stated c. Nursing implications are appropriate and complete Comments: 112 PATIENT PROFILE AND ASSESSMENT Student Name: ________________________________ Date: _____________________ I. PATIENT PROFILE: (subjective data) Patient Name (initials):_______ Date of Birth: _____________ Birthplace: _______________ Occupation: ________________________________ Highest grade of formal education: _________ Age: ______ Sex: ______ Race: _______________ Marital Status: _______________ Statement of Present Problem and Duration: (Reason for seeking medical attention & when problem started) A. PATIENT: (Use the words in italic as a prompt for system specific illness/disease, previous hospitalizations that the student should inquire about. State what, when, and outcome. Do not leave any section blank. If no problems, state none or patient denies problems.) Neurological: (headaches, migraines, weakness, ataxia, tics, tremors, seizures, vertigo, syncope, diminished sense of smell, touch, sensation, taste, numbness, tingling, head injury, LOC) Psychological: (depression, anxiety, eating disorder, schizophrenia, bipolar disorder) Integumentary: (eczema, seborrhea, alopecia, skin cancer, hives, dryness) Eyes: (glaucoma, cataract, vision problems, wears corrective lens) Ears/Nose/Throat & Neck: ( difficulty hearing, use of hearing aid, dental caries, bleeding gums, sinus problems, nose bleeds) Respiratory: (COPD, emphysema, asthma, bronchitis, sarcoidosis, pneumonia, tuberculosis, shortness of breath, cough) Cardiovascular: (heart problems, hypertension, chest pain, palpitations, myocardial infarction, coronary artery disease, valvular disorder, atherosclerosis, thrombophlebitis, varicose veins, edema) Gastrointestinal: (indigestion, ulcer, gastric reflex disease, dysphagia, gallbladder disease, pancreatitis, bowel disorders, hemorrhoids, constipation, diarrhea, incontinence, meal pattern, special needs, cultural restrictions, appetite) Urinary: (kidney disease, incontinence, kidney stones, nocturia, hematuria, urgency, retention, dialysis, end stage renal disease) Musculoskeletal: (muscle weakness, decreased range of motion/mobility, joint pain/stiffness/swelling, leg cramps, back pain, history of trauma, arthritis) Male Reproductive: (testicular mass/cancer, erectile dysfunction, impotence, undescended testicle, prostate disease/cancer, dysuria) Female Reproductive: (labial/vulvular pain/swelling, painful intercourse, uterine/ovarian problems, PID, dysmenorrhea, irregular menses, menopause, breast disease) Endocrine: (diabetes, thyroid disease, goiter) Lymph Nodes: (lymphoma, Hodgkin’s disease) Hematological: (leukemia, anemia, hemophilia, bruising, blood transfusions~when and why) Immunological: (frequent infections, diminished immune status, human immunity virus (HIV) infection) Surgical History: (what for, when, any complications or adverse reaction to anesthesia) Current Medications : (use attached medication list form) Prescription: Over-tLast updated: Fall 2020 Care Plan Tips and Examples *Follow exactly what is on the Care Plan Grading Rubric. Section by section, line by line. Patient Introduction o Remember to avoid identifiers to maintain patient confidentiality: No initials, no birthdate, decade for age, do not give name of facility or hospital. Stage age in designated range as listed on the rubric. o Write in paragraph narrative format, following APA format, and complete sentences. o Include every section in the rubric. Patient Introduction (Specific Example) Patient is (give age group 66-74, 75-85, >85 years) Caucasian female. Patient was admitted to the skilled nursing facility on 9/21/12 after suffering an acute CVA the day after she had surgery for a hip fracture to her right femoral neck which was required due to a fall at home. Patient suffers from mild expressive aphasia as a result of the CVA. Her memory of the events surrounding the fall are not clear. She states that she was not with anyone at the time of the fall and she does not remember if she blacked out or lost consciousness. She states that someone found her in her apartment and she was taken to Hospital where she said she had a “rod” put in her hip. Patient has a past surgical history of hemiarthroplasty for her right femoral neck fracture, back surgery, lumpectomy for breast cancer, and tonsillectomy. She also has a past history of HTN, DM, high cholesterol and glaucoma. Patient’s father and mother died of natural causes. Some diabetes in the family. Patient has lived in the DC area all her life. She attended college and graduate school and states that she got a degree in food service management and she “fully enjoyed” that. She was never married and does not have any children. However, she states that she has many friends who she sees and visits with often. She enjoys visiting with all her friends and spending time with people. She expects to be able to return home to her apartment at an assisted living facility within the next week. She says that she has a lot of friends who will help her. She also has a cousin who is a surgeon who has been helping with everything. Patient does not have any known allergies. Code: Attempt CPR Last updated: Fall 2020 Assessment and Interpretation *Physical Assessment: Use your textbook! Problems identified are stated as NANDA Diagnosis and follow the assessment. Include all body systems. Example: Assessment: 10/26/2025 and 11/2/2025 Problems: G-U: 10/26/25 Patient denies problems with urination. Patient states that she urinates 4-5 times a day and states that her urine appears “clear with nothing abnormal”. When asked about fluid intake, patient states that she should “probably drink more water” and she then proceeded to drink some of her water at her bedside. When the patient showed me the scar on her right hip from her hip surgery, I noticed she also