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1. NURSING ASSESSMENT
Name ofinstitution________________________________________________________
Date of assessment________________________________________________________
Name ofStudent Nurse_____________________________________________________
1. Patient’sPersonal Data
 Patient’sname______________________________________________
 Marital status_______________________________________________
 Age _________________________Sex___________________________
 Religion____________________________________________________
 Languagesspoken____________________________________________
 Educational level_____________________________________________
 Previoushospitalexperience:yes/No____________________________
If yes,brief description)________________________________________
___________________________________________________________
 Otherassociate illness:IHD/HTN/DM/TB/Others___________________
 Allergiesyes/no(specify)_______________________________________
2. SOCIAL DATA
i. Positioninthe family:_________________________________________
ii. No.Of children_______________________________________________
iii. Otherdependents:____________________________________________
iv. Housingfacilities:Slum/Kuccha/Pucca/Well built___________________
v. Livinglocality: urban/rural
vi. Toiletfacility: ownlatrine/publiclatrine/openfield
vii. Water supply: sufficient/insufficient
viii. Source of water:publicwatersystem(tap)/tubewell/well/river___________________
ix. Electricsupply:publicelectricsupplysystem/kerosene lamp/other_______________
3. ActivitiesOf Daily Living (ADL)
i. Personal Hygiene
 Bathingpattern:daily/alternate/notfix/lessfrequent
 Water preference:hot/cold/lukewarm
 Oral care:one time/twotimesaday
Uses fingercleaning/toothbrush/neemstick/powder/charcoal
ii. Sleepingpattern:soundsleep/disturbedsleep
iii. Habits:
 Smoke:yes/no
 Drinks:yes/ no ___if yes:habitual/social/occasional/addict
 Chews:yes/no___ if yes: specify_____________________________
 Anyotherhealthaffectinghabit______________________________

2. iv. Nutrition
 Likes/diskesof food_______________________________________
 On anydiettherapy:saltfree/diabetic/other__________________
 Foodpatternveg/non veg__________________________________
 Appetite good/moderate/ poor______________________________
v. Elimination
 Bowel pattern
 No of bowel movement/day_________________________
 Anyotherdifficulty( constipation/diarrhea)______________
 Urinary pattern
 Frequencyof micturation________times/day& ________ times/night
 Anyotherdifficulty( nocturia/dysuria,incontinence) _____________
vi. Reproductive ( forfemale patients)
 Menstruation:regular/irregular/dysmenorrhea
 If amenorrhea,LMP:______________________________________
4. Health Assessment
i. General appearance: Thin/Obese/normal
ii. Hair: groomed/infectedwithpediculosis/dandruff
iii. Level of consciousness:conscious/semi conscious/unconscious
iv. Behaviour:anxious/distressed/cheerful
v. Pain:yes/nospecify:____________________________________________
vi. Skin:normal/edematous/lossof skinturgor/rashes/jaundice/discoloration
vii. Vision:normal/Wearsglasses
viii. Hearing:normal/impaired/useshearingaids
ix. Oral inspection
 Mouth: normal/halitosis/sore throat/leukoplakia
 Teeth:normal(goodcondition)/decay/stained/looseteeth/dentures
 Tongue:moist/dryand coated/stained/other_________________
x. Mobility:ambulatory/difficultyinambulation/usescrutches/walkingaid
xi. Vital signs:
 Temperature:_____________________________
 Pulse:_________________/minute
 Respiration:____________/ minute
 B.P.:______________________
5. ProblemsIdentification( withpriorities)
i. ___________________________________________________________________________
ii. ___________________________________________________________________________
iii. ___________________________________________________________________________
iv. ___________________________________________________________________________
v. ___________________________________________________________________________