CAPITOL UNIVERSITYCollege of Nursing

NURSING ASSESSMENT FORM

A. Demographic Data

Name of Client _________________________________________ Unit/Ward __________ Bed ________Age _________ Sex _________ Civil Status _____________ Religion ___________________________Date of Admission _______________________ Medical Diagnosis ____________________________________________Examiner ________________________________ Information given by ________________________________________

B. Vital Signs

Temp ___________ oral axilla rectal BP ___________ lying sitting standingPulse ___________/ min. regular irregular Resp ___________/ min. regular irregularHeight ___________ cm. Weight ____________ kg.

C. Health Patterns Assessment: Complete information, including patient’s words. Indicate N/A if non-applicable. Circle, code, or check all findings as appropriate.

1. Health Perception and Health Management PatternReason for hospitalization/chief complaint ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________History of present illness _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Previous hospitalizations/surgeries__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What other health problems have you had? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Things done to manage health _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Statement of patient’s general appearance _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Tobacco use: Yes No Used to smoke ______________ packs/day for __________ yearsAlcohol use: Yes No Amount: _______________ Frequency: _________________ Duration: _____________Coffee/Cola/Tea Intake: Yes No Amount: ___________ Frequency: ____________ Duration: _____________Recreational/Illicit Drug use: Yes Specify: _____________________ No Allergies: Yes (list with reaction experienced) No Food: __________________________________________ Medications:_____________________________________ Others: ________________________________________________________________________________________

Medications:NAME DOSE SCHEDULE INDICATIONS

Have you been taking your medication(s) as prescribed? ________________________________________________________OTHER PERTINENT DATA: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Nutrition and Metabolic PatternSpecial diet? _____________________________________________ Supplements: ________________________________Pattern of daily food/fluid intake (describe amount/quantity) _________________________________________________________________________________________________________________________________________________________Appetite: ________________________________________________ Wt. loss/gain? ________________________________Nausea/Vomiting: _________________________________________ Hematemesis Coffee-ground vomitus

Food/eating discomforts________________________________ GI pain ___________________________________________Nutritional state: well-nourished poorly nourished obesity cachexia

Mouth: Lips: pinkish pallor cyanosis dryness/cracks lesions: ________________________________ Mucosa: pinkish pallor cyanosis Tongue: midline R/L deviation atrophy fasciculation Teeth: complete missing teeth caries dentures: ________________ Gums: pinkish pallor bleeding tenderness

Pharynx: Uvula: midline R/L deviation Mucosa: pinkish pallor reddish Tonsils: not inflamed R/L inflamed R/L with exudate Posterior Pharynx: inflammation/congestion

Neck: Trachea: midline R/L deviation Cervical lymph nodes: lymphadenopathy tenderness Thyroids: non-palpable enlarged Others: neck enlargement normal ROM neck rigidity

Skin: General Color: pinkish pallor jaundice dusky cyanotic flushed mottled Texture: smooth rough others: __________________________ Turgor: supple firm dehydrated others: ___________________________ Temperature: warm cool others: ______________ Moisture: dry moist/clammy oily Others: petechiae ecchymosis hematoma lesions/rashes: ____________________________________ edema: ____ pitting ____ non-pitting ____ pedal: R/L ______ bipedal Grading: ____________

Wounds/drains/dressings: _________________________________________________________________________________Intravenous fluids _______________________________________________________________________________________OTHER PERTINENT DATA: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Elimination PatternUsual bowel pattern (describe character of stool, frequency, discomforts) __________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of last BM: ______________________ Melena HematocheziaAny problems with hemorrhoids/incontinence? _______________________________________________________________Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies” anti-diarrheals): ____________________________________________________________________________________________________________________

Abdomen: General : superficial veins straie scars/lesions: ____________________ Configuration: symmetrical asymmetrical flat globular protuberant scaphoid Bowel Sounds: normoactive hyperactive hypoactive absent Percussion: tympanitic hypertympanitic dullness at _________________________________ fluid wave shifting dullness Palpation: muscle guarding direct tenderness rebound tenderness bladder distention organomegaly: ___ liver ___ spleen masses at _____________________________________

Usual urinary pattern (describe frequency, character, amount, problem in control, etc.) ______________________________________________________________________________________________________________________________________ dysuria hematuria nocturia retention flank pain polyuria oliguria anuriaExcess perspiration/nocturnal sweats: _______________________________________________________________________OTHER PERTINENT DATA: ___________________________________________________________________________________________________________________________________________________________________________________

4. Activity – Exercise PatternExercise Pattern? (Type, Regularity) _______________________________________________________________________Leisure Activities? _____________________________________________________________________________________

Cardiovascular Status: chest pain/radiation: _______________________ palpitations dyspnea on exertion orthopnea paroxysmal nocturnal dyspnea jugular vein distention Precordial area: flat bulging tenderness heave thrill Point of Maximal Impulse (PMI) _____________________ Apical rate & rhythm _____________________________ Heart Sounds: distinct regular faint irregular S1 < > S2 at the base S1 < > at the apex Others: S3 S4 Murmur best heard at ________________ Pericardial rub Peripheral pulses: symmetrical regular absent faint/weak strong bounding Capillary refill __________________________ clubbing Presence of Pacemaker/A-V Shunt/Hemodynamic monitoring ______________________________________________

Respiratory Status: Breathing Pattern: regular irregular eupnea hyperpnea tachypnea bradypnea dyspnea: rest / exertion use of accessory muscles ICS retractions/bulging pain on respiration Shape of Chest: Anterior-Posterior-Lateral Ratio AP_____: L_____ barrel chest funnel pigeon Lung Expansion: symmetrical R / L decreased/lag Vocal/Tactile Fremitus: symmetrical decreased / increased at _________________ Percussion: resonant dullness at ___________________ hyperresonant at ___________________ Breath Sounds: vesicular bronchovesicular at _________________ bronchial at __________________ rales/crackles at______________ wheezes at ___________________ rhonchi pleural friction rub Cough: productive non-productive Sputum: color _________ amount________ consistency __________

O2 supplement/ventilatory assistance_______________________________________________________________________ Resp. tubes (e.g. ET, trach, chest tube – describe secretions/drainage)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________

Activities of Daily Living/ Mobility Status: Use the Activity Level Code below to assess ADL & mobility status ADL Status Mobility Status 0 – total independence Feeding ________ Meal Preparation_____ Bed mobility _____________1 – assist with device Bathing ________ Cleaning __________ Chair/toilet transfer________2 – assist with person Dressing _______ Laundry __________ Ambulation ______________3 – assist with device & person Grooming ______ Toileting __________ R.O.M. _________________4 – total dependenceReasons for ADL/Mobility limitation _______________________________________________________________________Device used for assistance ________________________________________________________________________________Exercise pattern (describe type, regularity) ___________________________________________________________________

Back and Extremities: Range of Motion: full symmetrical decreased ROM (specify joint) _________________ Joint tenderness/pain joint swelling at ________________ varicose veins deformities _____________ Muscle tone and Strength: equally strong symmetrical in size R / L Upper / Lower Atrophy R / L Upper / Lower Paresis R / L Upper / Lower Paralysis Spine: midline Kyphosis Lordosis Scoliosis Gait: coordinated smooth uncoordinated shuffling staggering OTHER PERTINENT DATA ___________________________________________________________________________________________________________________________________________________________________________________

5. Cognitive – Perceptual Pattern

Level of Consciousness: conscious alert confused drowsy stuporous comatose others_______Orientation: oriented disoriented to : time / person / placeEmotional state: calm worried/anxious restless others: ______________________________________Appropriate behavior/communication: ______________________________________________________________________ dizziness numbness tingling sensation

Head: normocephalic asymmetrical enlarged masses: _____________ others: ___________________ Facial Movements: symmetrical asymmetrical: lag at R / L Fontanels: closed sunken bulging open: specify _____________________ Hair: fine coarse dry normal/even distribution alopecia Scalp: clean dandruff lice wounds/scars/lesions: specify_______________________________

Eyes: Lids: symmetrical R / L edema/swelling R / L ptosis lesions: __________________________ Periorbital region: edema sunken discoloration Conjunctiva: pink pale lesions discharges Cornea & Lens: opacity: R / L lesions: __________ Sclera: anicteric subicteric icteric hemorrhages Pupils: equal: size _____mm. unequal: R= _____mm. L= _____mm. Reaction to Light: R - brisk sluggish fixed L - brisk sluggish fixed Reaction to Accommodation: uniform constriction / convergence unequal constriction / convergence Visual Acuity: grossly normal farsighted nearsighted wears eyeglasses/contact lenses Peripheral Vision: intact/full decreased/ limited: _________________________

Ears: External Pinnae: normoset symmetrical tenderness lesions gross abnormalities ______________ External Canal: discharge: ___foul smelling ___ serous ___ purulent ___mucoid Cerumen: ____impacted Tympanic Membrane: intact Gross Hearing: normal decreased symmetrical R / L deafness

Nose: alar flaring shallow nasolabial fold Septum: midline deviated perforated Mucosa: pinkish pale reddish Discharge: serous mucoid purulent bloody Patency: both patent R / L obstruction masses/lesions: describe __________________________________

Gross Smell: normal/symmetrical R / L olfactory deficiency

Sinuses: tenderness: ____ maxillary ____ frontal

Cognition: Primary language _________________________ Speech deficit _____________________________________ Educational attainment ______________________________________________________________________________ Any learning difficulties? ____________________________________________________________________________ Any change in memory lately? ________________________________________________________________________

Pain: no problem problem ( describe location, type, intensity, onset, duration of pain) ________________________ _________________________________________________________________________________________________

Methods of pain management: ________________________________________________________________________

6. Sleep – Rest Pattern Usual sleep/rest pattern: _______________________________________________________________________________ Adequate yes no Factors affecting sleep/rest: ______________________________________________________ Methods to promote sleep _____________________________________________________________________________ History of sleep disturbances ___________________________________________________________________________

7. Self-perception and Self-concept Pattern How do you describe yourself ? ________________________________________________________________________ Are there any ways you feel differently about yourself since you’ve been ill/hospitalized? __________________________ __________________________________________________________________________________________________ Description of non-verbal behaviors: ____________________________________________________________________ _________________________________________________________________________________________________

8. Role – Relationship Pattern Marital status _____________ Age and health of significant other _____________________________________________ Age and health of children ____________________________________________________________________________ __________________________________________________________________________________________________ Illnesses in the family ________________________________________________________________________________ Live alone family others: ___________________________________________________________________ Family feelings regarding illness/hospitalization ___________________________________________________________ __________________________________________________________________________________________________ Who are the people that will help you most at this time? _____________________________________________________ Occupation: (any stresses/hazards?) _____________________________________________________________________ Financial support system: ______________________________________________________________________________

9. Sexuality – Reproductive Pattern Any changes/problems with sexual relations? ________________________________________________________________Female: Menstrual pattern:___________________________________ Problems/changes: ____________________________ Date of LMP _________________________ Pregnancy history ____________________________________________ Use of birth control measure yes no N/A Type: _____________________________________________ Any problem with use ? ______________________________ Monthly self-breast exam yes no External Genitalia: Labia: symmetrical asymmetrical lesions __________________ pinkish discoloration edema Urethra: pinkish red/inflamed Vaginal Orifice Discharge: purulent bloody foul-smelling Others: swelling lumps/nodules Breast: equal unequal Surface: smooth retraction dimpling edema lesions tenderness masses at _____________________ others: __________________________

Male: Prostate problems? _____________________________ Monthly self-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

10. Coping – Stress Tolerance PatternHave you experienced any recent stressful situations in addition to your illness/hospitalization? Yes NoIf “Yes”, please describe briefly _________________________________________________________________________________________________________________________________________________________________________Are there any ways we can be of assistance? ______________________________________________________________How do you usually manage stresses? ___________________________________________________________________What do you do for relaxation? _________________________________________________________________________Support groups/counseling resources used: _______________________________________________________________Were they helpful? __________________________________________________________________________________

11. Value – Belief PatternReligion ____________________ Is it important in your life? How? ____________________________________________________________________________________________________________________________________________Religious practices ____________________________________________________________________________________________________________________________________________________________________________________Will illness/hospitalization interfere? ____________________________________________________________________