Cagayan De Oro City

COLLEGE OF NURSING
ASSESSMENT FORM

GENERAL INFORMATION
Patient’s Name: _______________________________________ Age: _________ Sex: __________
Address: ___________________________________________ Contact Number: ________________
Status: _____________________ Nationality ___________________ Income: __________________
Educational Attainment: ______________ Religion: ______________ Occupation: ______________
Name of Spouse/Guardian: ___________________________________________________________

Date of Admission (MM/DD/YY): _________________ Time of Admission: ___________________

Baseline Vital Signs: Blood Pressure: ______ Temperature: ______ Pulse Rate: _________
Weight upon admission (in Kilograms): _________ Height (in feet and inches): _________

CHIEF COMPLAINTS
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HISTORY OF PRESENT ILLNESS

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HOSPITALIZATION HISTORY

DATE OF ADMISSION NAME OF INSTITUTION DIAGNOSIS/INDICATION

ALLERGIES: Yes No

Food: _____________________ Medications: _____________________

Others: _____________________
BLOOD TYPE: ________ BLOOD TRANSFUSION HISTORY: Yes No

DATE OF TRANSFUSION INDICATION REACTION

MEDICATION HISTORY (Previously taken, maintenance, current, etc.)

DRUG NAME DATE TAKEN SCHEDULE INDICATIONS

LABORATORY EXAMS/IV FLUIDS

Date Diagnostic / Date done Date IV fluids/blood Date

ordered Laboratory (mm/dd/yy) ordered discontinued
(mm/dd/yy) exams (mm/dd/yy) (mm/dd/yy)

Have you been taking your medication(s) as prescribed? Yes No

Nutrition and Metabolic Pattern

Special diet: Yes No _________________
Supplements: Yes No _________________

Nutritional state:
Well-nourished Poorly nourished Obesity Cachexia

Mouth:
Lips
Pinkish Pallor Cyanosis Lesions
Dryness/cracks

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 deviation R/L exudates
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 ______________
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: _____________________________________________________________

Elimination Pattern

Usual bowel pattern (Describe character of stool, frequency, discomforts)

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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-
diarrheals: ____________________________________________________________________

Abdomen
General
Superficial Veins Striae Scars/lesions
Configuration
Symmetrical Asymmetrical Flat
Globular Protuberant Scaphoid
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.)
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Dysuria Hematuria Nocturia Retention

Flank pain Polyuria Oliguria Anuria

Excess perspiration/nocturnal sweats: _______________________________________________

Activity – Exercise Pattern

Cardiovascular Status
Chest pain/radiation Palpitations Dyspnea on exertion
Orthopnea Paroxysmal nocturnal dyspnea
Jugular vein distention

Precordial area
Flat Bulging Tenderness
Heave Thrill
Apical rate and rhythm _____________________
Heart Sounds
Distinct Regular Faint
Irregular
Others: S3 S4 Murmur best heard at ___________
Pericardial rub
Peripheral Pulses
Symmetrical Regular Faint
Strong Bounding
Capillary Refill __________________________
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
Resonant Dullness at ______________
Hyperresonant at _________________
Vocal/Tactile Fremitus
Symmetrical Decreased/increased at ____________
Percussion
Resonant Dullness at ___________ Hyperresonant at __________
Breath Sounds
Vesicular Bronchovesicular at ___________ Rhonchi
Bronchial at ___________ Rales/crackles 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)
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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) __________________________________________

Back and Extremities

Range of motion
Full Symmetrical Decreased ROM(indicate joint) ______
Joint tenderness/pain Varicose veins Deformities
Joint swelling at __________
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 Shuffling Staggering

Cognitive-Perceptual Pattern

Level of Consciousness
Conscious Alert Confused Drowsy
Stuporous Comatose Others ______________
Orientation
Oriented Disoriented to: Time / person / place
Emotional State
Calm Worried/anxious Restless Others

Dizziness Numbness Tingling sensation

Head:
Normocephalic Assymetrical Enlarged Masses
Others: __________
Facial Movements
Symmetrical Assymetrical: lag at R L
Fontanels
Closed Sunken Bulging Open: specify _______
Hair
Fine Coarse Dry Alopecia
 Normal/even distribution
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 and 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/convergence
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 Not impacted
Tympanic membrane
Intact Not 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 obstruction L obstruction
Masses/lesions (describe): _______________
 Gross smell
Normal/Symmetrical R olfactory deficiency L olfactory deficiency
Sinuses
Tenderness: Maxillary Frontal

Cognition
Primary language ____________________ Speech difficulties ____________________
Are there any learning difficulties? Yes No
Are there any change in memory lately? Yes No
Pain
No problem
Problem
Location ____________________
Type ____________________
Intensity ____________________
Onset ____________________
Duration ____________________

Methods of pain management ___________________________________

Sleep-rest pattern

Usual sleep/rest pattern ____________________

Adequate: Yes No
Factors affecting sleep/rest ________________________________________
Methods to promote sleep ________________________________________

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: ____________________________________

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
Labia: Symmetrical Asymmetrical Pinkish
 Discoloration Edema Lesion
Urethra:Pinkish Red/inflamed
Vaginal discharge
Purulent Bloody Foul smelling
Others: Swelling Lumps/nodules

Breast
Equal Unequal Tenderness
Surface:
Smooth Retraction Dimpling Edema
Lesions
Masses at: ____________________
Others ____________________

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

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 _____________________________________
 PATHOPHYSIOLOGY

Name of Patient: ____________________________________________________________________

Diagnosis: ________________________________________________________________________

Predisposing factors: Precipitating factors:

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Reference:
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