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Assessment tool
This document appears to be an assessment form used by a College of Nursing to collect patient information. It includes sections to document a patient's general information, chief complaints, medical history, vital signs, nutrition, elimination, activity levels, physical examination findings, cognition, and pain. The physical exam section includes detailed assessments of different body systems to document the patient's current health status.
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Assessment tool
- 1. Cagayan De OroCity 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 ANDMETABOLIC 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 Rangeof 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: PRECIPITATINGFACTORS: ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________
- 8. DIAGNOSTIC STUDIES ANDLABORATORY RESULTS Note: Place all the diagnostic studies done to the patient and indicate only significant results.
- 9. DISCHARGE PLAN Medications Exercise Treatment Health Teaching Outpatient check up Diet Spiritual
- 10. Cagayan de OroCity Bachelor of Science in Nursing HOSPITAL ROTATION MANUAL __________________________________ AREA OF ROTATION Clinical Instructor: _____________________________ Florig, Sharmaine Grace B. Name of Student