The first step of the nursing process in assessment and health assessment is a systematic method of collecting data. A registered nurse collects health data from a patient and compares it to the ideal state of health, while at the same time tries to identify a patient's strengths, weaknesses, health problems, and deficits. Below is an example of a health assessment completed using OLDCARTS.
General Survey
48 y/o male, 6'0" 180 lbs, A&O x3, 3mm PERRL, does not appear to be in pain or respiratory distress, skin warm and dry, BP 140/90, HR 70 strong and regular, RR 17 and regular, temp 98.7 F, LS clear AP bilateral, no edema noted.
CC- intermittent chest pain
Onset- two weeks ago
Location- left side, below at nipple line
Duration-last 5-10 minutes each time
Characteristics-dull, aching
Aggravating-exercise, stress
Related s/s- SOB, diaphoresis
Treatment-tylenol
Severity-8/10 pain, denies at this time
History of Present Illness
Last experienced pain one week ago, states "feeling pretty good now" , stress at work and alot of travel, pains are getting worse when they do occur
Current Medications
Metoprolol for blood pressure, Tylenol regularly for aches and pain, MVI daily
Allergies
Shellfish causes hives, denies any other allergies to food or environment
Past Medical History
High cholesterol, Hypertension
Past Surgical History
Inguinal hernia repair in 2003, screws in leg r/t previous fracture in 1994
Family History
Paternal grandparents are both deceased, cause unknown, father had stroke at 56 yrs old, maternal grandparents are both deceased, grandmother from breast cancer at 67 yrs old and grandfather from MI at 73 yrs old, mother has high cholesterol and diabetes, sister has diabetes.
Social History
Sales representative, smokes occasionally since 30 yrs, drinks six beers per week and occasional whiskey, denies recreational drugs, exercises 3-4 times per month, consumes two 8 ounce cups of coffee per day.
Wilson, S.F., & Giddens, J.F. (2009) Health Assessment for Nursing Practice. St.Louis: Mosby, Inc.
General Survey
48 y/o male, 6'0" 180 lbs, A&O x3, 3mm PERRL, does not appear to be in pain or respiratory distress, skin warm and dry, BP 140/90, HR 70 strong and regular, RR 17 and regular, temp 98.7 F, LS clear AP bilateral, no edema noted.
CC- intermittent chest pain
Onset- two weeks ago
Location- left side, below at nipple line
Duration-last 5-10 minutes each time
Characteristics-dull, aching
Aggravating-exercise, stress
Related s/s- SOB, diaphoresis
Treatment-tylenol
Severity-8/10 pain, denies at this time
History of Present Illness
Last experienced pain one week ago, states "feeling pretty good now" , stress at work and alot of travel, pains are getting worse when they do occur
Current Medications
Metoprolol for blood pressure, Tylenol regularly for aches and pain, MVI daily
Allergies
Shellfish causes hives, denies any other allergies to food or environment
Past Medical History
High cholesterol, Hypertension
Past Surgical History
Inguinal hernia repair in 2003, screws in leg r/t previous fracture in 1994
Family History
Paternal grandparents are both deceased, cause unknown, father had stroke at 56 yrs old, maternal grandparents are both deceased, grandmother from breast cancer at 67 yrs old and grandfather from MI at 73 yrs old, mother has high cholesterol and diabetes, sister has diabetes.
Social History
Sales representative, smokes occasionally since 30 yrs, drinks six beers per week and occasional whiskey, denies recreational drugs, exercises 3-4 times per month, consumes two 8 ounce cups of coffee per day.
Wilson, S.F., & Giddens, J.F. (2009) Health Assessment for Nursing Practice. St.Louis: Mosby, Inc.