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STI College of Nursing CDO

STI College of Nursing CDO

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  • 1. Cagayan De Oro City COLLEGE OF NURSING ASSESSMENT FORM GENERAL INFORMATION Patient’s Name: Age: Sex: Address: Status: Religion: Educational Attainment: Occupation: Nationality: Income: Name of Spouse/Guardian: Contact Number: Date of Admission (MM/DD/YY): Time of Admission: Baseline Vital signs: BP: T: PR: RR: Weight upon admission (in Kg): Height (in ft & in): CHIEF COMPLAINTS HISTORY OF PRESENT ILLNESS HOSPITALIZATION HISTORY ALLERGIES: Yes No (If yes, specify below) Food: Medications: Others: BLOOD TRANSFUSION HISTORY: Yes No (If yes, indicate below.) BLOOD TYPE: DATE OF TRANSFUSION INDICATION REACTION MEDICATION HISTORY (Previously taken, maintenance, current, etc.) DRUG NAME DATE TAKEN SCHEDULE INDICATIONS LABORATORY EXAMS/IV FLUIDS Date ordered (mm/dd/yy) Diagnostic / Laboratory exams Date done (mm/dd/yy) Date ordered (mm/dd/yy) IV fluids/blood Date discontinued (mm/dd/yy) Have you been taking your medication(s) as prescribed? Yes No DATE OF ADMISSION NAME OF INSTITUTION DIAGNOSIS/INDICATION
  • 2. A. NUTRITION AND METABOLIC PATTERN Special diet: Yes (specify) No Supplements: Yes (specify) No Nutritional state: Well-nourished poorly nourished Obesity Cachexia Mouth: Lips Mucosa Tongue Teeth Pinkish Pinkish Midline Complete Pallor Pallor Atrophy Caries _____ Cyanosis Cyanosis Fasciculation Missing teeth_____ Lesions R/L deviation Dentures _____ Dryness/cracks Gums Pinkish _____ Pallor _____ Bleeding _____ Tenderness _____ Pharynx: Uvula Mucosa Tonsils Posterior Pharynx Midline _____ Pinkish _____ not inflamed _____ Inflammation _____ R/L deviation _____ Pallor _____ R/L Deviation _____ Reddish _____ R/L Exudates _____ Neck: Trachea Thyroids Others: Midline _____ R/L deviation _____ Non-palpable _____ Neck enlargement _____ Lymphadenopathy _____ Tenderness _____ Enlarged _____ Normal ROM _____ Cervical Lymph Nodes _____ Neck rigidity _____ Skin: General Color Texture Temperature Moisture Pinkish _____ Smooth _____ Warm _____ Dry _____ Cyanotic _____ Rough _____ Cool _____ Moist/Clammy _____ Pallor _____ Others: Others: Oily _____ Flushed _____ _______________ ________________ Jaundiced _____ Mottled _____ Dusky _____ Others Petechiae _____ Ecchymosis _____ Hematoma _____ Lesions/Rashes _____ Edema: Pitting _____ (If pitting, specify below) Non-pitting _____ Pedal: R _____ L _____ Bipedal _____ Grading: _____ Wounds/drains/dressings: ____________________________________________________________________________________________ Intravenous fluids: __________________________________________________________________________________________________ B. ELIMINATION PATTERN Usual bowel pattern (Describe character of stool, frequency, discomforts) _________________________________________________________________________________________________________________ _ Date of Last BM (mm/dd/yy): ______________________________ Melena _____ Hematochezia _____ Are there any problems with hemorrhoids/incontinence? Yes _____ No _____ Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies”, anti-diarrheal) _________________________________________________________________________________________________________________ _ Abdomen General Configuration Percussion Palpation Superficial Veins _____ Symmetrical _____ Tympanitic _____ Muscle guarding ____ Striae _____ Asymmetrical _____ Hypertympanitic _____ direct tenderness ____ Scars/Lesions _____ Flat _____ Fluid wave _____ Rebound tenderness ____ Globular _____ shifting dullness _____ Bladder distention ____ Protuberant _____ Dullness at: Organomegaly: Scaphoid _____ __________________ Liver _____ Spleen ____ Masses at: _____________________
  • 3. Usual urinary pattern (Describe frequency, character, amount, problem in control, etc.) _________________________________________________________________________________________________________________ _ Dysuria _____ Hematuria _____ Nocturia _____ Retention _____ Flank pain _____ Polyuria _____ Oliguria _____ Anuria _____ Excess perspiration/nocturnal sweats: ______________________________________________ C. ACTIVITY – EXERCISE PATTERN Cardiovascular Status Chest pain/radiation _____ Jugular vein distention _____ Dyspnea on exertion _____ Orthopnea _____ Palpitation _____ Paroxysmal nocturnal dyspnea _____ Precordial area Heart Sounds Peripheral pulses Flat _____ Distinct _____ Symmetrical _____ Bulging _____ Regular _____ Regular _____ Tenderness _____ Faint _____ Faint _____ Heave _____ Irregular _____ Strong _____ Thrill _____ Others: Bounding _____ Apical rate and rhythm: S3 _____ S4 _____ _____________________ Preicardial rub _____ Capillary Refill __________________________ Presence of Pacemaker/A-V Shunt/Hemodynamic monitoring ___________________________________ Respiratory Status: Breathing Pattern Shape of chest Lung Expansion Regular _____ Irregular _____ Normal APL ratio _____ resonant _____ Eupnea _____ Hyperpnea _____ Barrel chest _____ Dullness at: Tachypnea _____ Bradypnea _____ Funnel _____ ______________ Dyspnea _____ Rest _____ Pigeon _____ Hyperresonant at: Exertion _____ ______________ Use of accessory muscles _____ ICS retractions/bulging _____ Pain on respiration _____ Vocal/Tactile Fremitus Percussion Breath Sounds Symmetrical _____ Resonant _____ Rhonchi _____ Decreased/increased at: Dullness at: Bronchovesicular at ________________ ____________________ ______________ Rales/crackles at ________________ Hyperresonant at: Bronchial at ________________ ______________ Pleural Friction Rub ________________ Wheezes at ________________ Cough Productive _____ Non-productive _____ Sputum Color _________ Amount __________ Consistency __________ O2 supplement/ventilatory assistance __________________________________________________ Respiratory Tubes (e.g. ET, trach, chest tube/describe secretions and/or drainage) ___________________________________________________________________________ Activities of Daily Living/Mobility Status Use the Activity Level Code below to assess ADL & Mobility Status 0- Total Independence 1- Assist with Device 2- Assist with Person 3- Assist with Device Person 4- Total Dependence ADL Status Mobility Status Feeding _____ Meal Preparation _____ Bed Mobility _____ Bathing _____ Cleaning _____ Chair/Toilet Transfer _____ Dressing _____ Laundry _____ Ambulation _____ Grooming _____ Toileting _____ R.O.M. _____ Reasons for ADL/Mobility Limitation ____________________________________________________________________________ Device used for assistance __________________________________________________________________________ Exercise pattern (describe type, regularity) ___________________________________________________________
  • 4. BACK AND EXTREMITIES Range of motion Muscle tone and strength Decreased ROM (indicate joint) _________ equally strong __________ Joint tenderness/pain _________ Symmetrical in size __________ Varicose veins _________ R/L Upper/Lower extremities __________ Deformities _________ R/L Upper/Lower Paresis __________ Joint swelling at : __________________ R/L Upper/Lower Paralysis __________ Spine Gait Midline _____ Lordosis _____ Coordinated _____ Shuffling _____ Kyphosis _____ Scoliosis _____ Smooth _____ Uncoordinated _____ Staggering _____ D. COGNITIVE – PERCEPTUAL PATTERN Level of Consciousness Conscious _____ Alert _____ Confused _____ Drowsy _____ Stuporous _____ Comatose _____ Others ______________ Orientation Emotional State Oriented _____ Calm _____ Worrried/Anxious _____ Restless _____ Disoriented to: Dizziness _____ Numbness _____ Tingling Sensation _____ Time/Person/Place _____ Others: ________ Head: Normocephalic _____ Assymetrical _____ Enlarged _____ Masses _____ Others: _______ Facial Movements Fontanels Hair Scalp Symmetrical _____ Closed _____ Fine _____ Clean _____ Assymetrical: Sunken _____ Coarse _____ Dandruff _____ lag at R _____L _____ Bulging _____ Dry _____ Lice _____ Open: specify _____ Alopecia _____ Wounds/scars/lesions (specify) ________________________ Eyes: Lids Periorbital region Conjunctiva Cornea and lens Symmetrical _____ Edema _____ Pink _____ Opacity: R/L edema/swelling _____ Sunken _____ Pale _____ R _____ L _____ R/L ptosis _____ Discoloration _____ Lesions _____ Lesions _______ Lesions _____ Discharges _____ Sclera Visual Acuity Peripheral vision Reaction to accomodation Anicteric _____ grossly normal _____ Intact/Full _____ Uniform constriction/convergence Subicteric _____ Farsighted _____ Decreased/Limited _____ __________________________ Icteric _____ nearsighted _____ Unequal constriction/convergence Hemorrhages _____ Wears eyeglasses/convergence __________________________ ___________________ Pupils Equal _____ size _____ mm Unequal: R= ___ mm L= ___ mm Reaction to light: R: brisk _____ sluggish _____ fixed _____ L: brisk _____ sluggish _____ fixed _____ Ears External Pinnae External canal Tympanic membrane Gross Hearing Normoset _____ Discharge: Intact ______ Normal _____ Symmetrical _____ Foul smelling _____ Not intact _____ Decreased _____ Tenderness _____ Serous _____ Symmetrical _____ Lesions _____ Purulent _____ R/L deafness _____ Gross abnormalities: Mucoid _____ _________________ Cerumen: Impacted _____ Not impacted _____
  • 5. Nose Alar flaring _____ Shallow nasolabial fold _____ Septum Mucosa Discharge Patency Midline _____ Pinkish _____ Serous ____ Both patent _____ Deviated _____ Pale _____ Mucoid ____ R obstruction _____ Perforated _____ Reddish ______ purulent ____ L obstruction _____ Bloody ____ Masses/lesions (describe): ____________________ Gross smell Sinuses Normal/Symmetrical _____ Tenderness _____ R olfactory deficiency _____ Maxillary _____ L olfactory deficiency _____ Frontal _____ Cognition Primary language _________________________________________ Speech difficulties ____________________ Are there any learning difficulties? Yes ______ No _____ Are there any changes in memory lately? Yes _____ No _____ Pain No problem __________ Problem __________ Location ____________________ Type ____________________ Intensity ____________________ Onset ____________________ Duration ____________________ Methods of pain management ________________________________________________________________ E. SLEEP – REST PATTERN Usual sleep/rest pattern ______________________________________________________________________ Adequate: Yes _____ No _____ Factors affecting sleep/rest _____________________________________________________________________ Methods to promote sleep _____________________________________________________________________ F. SELF – PERCEPTION AND SELF – CONCEPT PATTERN How do you describe yourself? _______________________________________________________________________ Are there any ways the patient feel differently about his/herself since he/she has been ill/hospitalized? ______________ ________________________________________________________________________________________________ Description of nonverbal behaviors: __________________________________________________________________ G. SEXUALITY – REPRODUCTIVE PATTERNS Are there any changes/problems with sexual relations? _____________________ Female Menstrual pattern ____________________ Date of LMP ____________________ Pregnancy history _________________________________________________________ Use of birth control measure: Yes _____ Type: __________________________ No _____ N/A Monthly self-breast exam: Yes _____ No _____ External Genitalia Urethra Vaginal Discharge Labia: Pinkish _____ Purulent _____ Symmetrical _____ Red/inflamed _____ Bloody _____ Asymmetrical _____ Foul smelling _____ Edema _____ Others: Lesion _____ Swelling _____ Lumps/nodules _____ Breast Equal___________ Unequal _____________ Tenderness________________ Surface: Smooth _____ Retraction _____ Dimpling _____ Edema _____ Lesions _____ Masses at: ____________________ Others ____________________
  • 6. Male Prostate problems : Yes______ No________ Monthly testicular exam : Yes______ No________ Penis Discharge________ Nodules/growths/lesions__________ Tenderness______________ Scrotum Equal shape w/L lower than R _____ Non-tender _____ R/L enlargement _____ R/L undescended testes _____ Tenderness _____ Nodules/growths/lesions _____ Others: Hernia _____ Hydrocoele _____ H. COPING – STRESS TOLERANCE PATTERN Have you experienced any recent stressful situations in addition to your illness/hospitalization? Yes _____ No _____ If “yes”, please describe briefly ______________________________________________________________________________ How do you usually manage stresses? _______________________________________________________________________ What do you do for relaxation? _____________________________________________________________________________ Support groups/counseling resources used ____________________________________________________________________ INSTRUCTION: Place an X to the specific area of abnormality during your Physical Assessment _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________ _________________________ ____________________________
  • 7. PATHOPHYSIOLOGY PREDISPOSING FACTORS: PRECIPITATING FACTORS: ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________
  • 8. DIAGNOSTIC STUDIES AND LABORATORY RESULTS Note: Place all the diagnostic studies done to the patient and indicate only significant results.
  • 9. DISCHARGE PLAN Medications Exercise Treatment Health Teaching Out patient check up Diet Spiritual
  • 10. Cagayan de Oro City Bachelor of Science in Nursing HOSPITAL ROTATION MANUAL __________________________________ AREA OF ROTATION Clinical Instructor: _____________________________ Florig, Sharmaine Grace B. Name of Student