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Adult Assessment Format With Example

The document outlines the assessment of Mr. Ramesh Kumar, a 45-year-old male farmer, who presents with a cough and breathlessness. He has a history of hypertension and smokes regularly, with physical examination revealing bilateral wheezing and nasal congestion. The nursing diagnosis indicates ineffective airway clearance, and health education on smoking cessation and hydration was provided, with a follow-up visit planned.

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1K views2 pages

Adult Assessment Format With Example

The document outlines the assessment of Mr. Ramesh Kumar, a 45-year-old male farmer, who presents with a cough and breathlessness. He has a history of hypertension and smokes regularly, with physical examination revealing bilateral wheezing and nasal congestion. The nursing diagnosis indicates ineffective airway clearance, and health education on smoking cessation and hydration was provided, with a follow-up visit planned.

Uploaded by

praveenkotla1941
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Community Health Nursing – Adult

Assessment Format (with Example)


1. Identification Data
 Name: Mr. Ramesh Kumar
 Age: 45 years
 Sex: Male
 Marital Status: Married
 Occupation: Farmer
 Education: Secondary School
 Address: Village X, District Y
 Date of Assessment: 20-06-2025
 Place of Assessment: Home Visit

2. Chief Complaints
 Complains of cough and breathlessness since 1 week.

3. History of Present Illness


Started with mild cough and gradually developed breathlessness. No fever. No known
allergies.

4. Past Medical History


History of hypertension for 3 years. On regular medication. No history of hospitalization.

5. Family History
Father had diabetes and hypertension. No hereditary respiratory illness reported.

6. Personal History
 Diet: Mixed
 Appetite: Normal
 Sleep: Disturbed due to cough
 Bowel Habits: Regular
 Bladder Habits: Normal
 Addictions: Smokes 4-5 beedis/day for 20 years
7. Physical Examination
 General Appearance: Thin built, alert, conscious
 Height: 165 cm
 Weight: 58 kg
 BP: 140/90 mmHg
 Pulse: 88 bpm
 Respiration: 24 breaths/min
 Temperature: 98.6°F
 Skin: Normal
 Eyes: Normal
 Ears: Normal
 Nose: Nasal congestion
 Mouth: Dry
 Chest: Bilateral wheezing present
 Heart Sounds: Normal
 Abdomen: Soft, non-tender
 Limbs: No edema

8. Investigations
Blood Pressure and Respiratory Rate recorded. No lab investigations done yet.

9. Nursing Diagnosis
Ineffective airway clearance related to accumulation of secretions as evidenced by
productive cough and breathlessness.

10. Health Education Given


Advised to reduce smoking, maintain hydration, steam inhalation, and consult PHC for
further check-up.

11. Nurse’s Remarks


Needs medical evaluation and cessation of smoking. Follow-up visit planned after one week.

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