Lebanese University

Faculty of Public Health

V
Nursing Sciences Department

Patient Assessment form

Students Name: _________________

Year/Semester:__________________
Training Field: __________________
Date: __________________________
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Data Collection:
Patient Name: Patient Number: Bed:
Age: Gender: Male Marital Status: Single Married
Female Widowed Divorced
Admission Date: Admitting diagnosis: Admitting Physician:

Admitted through: Height: Weight: No of children: Blood Group:

Personal Articles: Allergies: Habits:
Denture: Upper Alcohol: Yes No ___ cup/day
Lower Coffee: Yes No ___ cup/day
Hearing Aids: Right Left Allergies Yes No Specify Smoke: Yes No ___ pack/day
Eye Glasses: Yes No Food Exercise: Yes No
Contact lenses: Yes No Drugs Bubbly: Yes No
Prosthesis: __________________
Other Others: _________________
Assisting devices: ____________
Allergy Band: Yes No
Medical History Surgical History
P F Medical History P F Medical History
Heart disease Hypertension
Diabetes Blood disorder Date Loc. Type
Lung Disease Rheumatic disorder
Dyslipidemia Liver Disorder
Prostate Problem Kidney Disease
Stroke Mental Disorder
Cancer Seizures
Others: ______________________________________

Pre-Admission Medication List Functional level

Activity Dependant Independant
Medication Route Dose Frequency Last dose taken In Bed

Ambulate

Daily act.
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Female Reproductive system

Not applicable

Gravida: ________ Para: ________

Abortion: _______ LMP: ________

Menopausal period: _______________

Vital Signs Temp:___oC Respiratory:___ /min Pulse:___/min BP:____ mmHg

Chief Complaints/ Present illness

(Onset of sickness, duration, symptoms, investigations)
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

. Orders:
Date & Orders Remarks
Time
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Orders:
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

. Lab Results:
Lab Test Normal Pt. Result Pt. Result Pt. Result Remark
Range Date: Date: Date:
WBC
RBC
Hemoglobin
Hematocrit
Neutrophils
Eosinophils
Lymphocytes
Monocytes
Platelets
Complete Blood Count

Glucose
BUN
Creatinine
Sodium
istry
ChemPotassium
Calcium
Magnesium
Chloride
Carbon dioxide

PT
PTT
INR

Coagulation
Cholesterol
Triglycerides
Lipids HDL
LDL
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Lab Test Normal Pt. result Pt. Result Pt. Result

Range Remarks
Date: Date: Date:
Color
Clarity
Specific Gravity
pH
Leukocytes
Nitrates
Urine Anal ysis
Protein
Glucose
Ketone
RBCs
WBCs
Bacteria

pH
PaCO2
ABGs PaO
2
SaO2
HCO3

Others

. Diagnostic Procedures:
Date Procedure Result Analysis
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Consultation:
Doctor Consulted Specialty Recommendations Remarks

. H.G.T. (if applicable):

Date & Time Result Insulin Administered Insulin Protocol

I. Flow Sheet (if applicable):

Date & Time
Temp
BP
HR
RRSigns
Vital
Intake
Output
In/Ou t
Balance
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Others
. Physical Assessment:
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Level Alert Confused Lethargic Obtunded Stupor Comatose

of
Consciousness
Oriented Disoriented
Level of Orientation Time Place Person

Glasgow Coma Scale Eye Opening Verbal Response Motor Response

(for critical patients) 4 Spontaneous 5 Oriented 6 Verbal Command
3 Verbal Command 4 Disoriented 5 Localized Pain
2 Pain 3 Use inappropriate words 4 Flex & Withdrawal
1 No Response 2 Incomprehensive words 3 Decorticate
1 No Respone 2 Decerebrate

Neurological Score: 1 No Response

/15(Decorticate = flexes abnormally/ Decerebrate = flexes normally)
Pupils
PERRLA or
Equal: Yes No ( Larger: Rt Lt) Round: Yes
No ( Abnormal: Rt Lt)
Reaction: Brisk Sluggish ( No Reaction: Rt Lt)
Reactive to light: Yes No ( Accommodation: Rt Lt)
Sensory
Dizziness Numbness Tingling location: __________________
Vision: Normal Deficit (Rt , Lt) Hearing: Normal Deficit (Rt , Lt)
Motor Power

Neck: ____ RUE: ____ LUE: ____ RLE: ____ LLE: ____
(5 = normal, 4 = 75% normal, 3 = 50% normal, 2 = 25% normal, 1 = paralysis)
Movement

Normal Limited Range of Motion Unsteady Gait Tremors

Speech Weakness Paralysis

Reflexes
Normal Slurred Aphasia Incomprehensive

Babinski: Positive Negative Gag: Positive Negative

 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

I. Physical Assessment:
Respiratory Rate: ______ b/min O2 Therapy: ______ SpO2: ____%
Chest Expansion
Symmetric Asymmetric
Breathing Pattern
Regular Irregular Shallow Dyspnea ( at rest on exertion)
Apnea Bradypnea Tachypnea Orthopnea Accessory muscle use
Breathing Sound
Clear Rt Lt Absent Rt Lt
Cough
Res piratory Diminished Rt Lt Wheezes Rt Lt
Rhonchi Rt Lt Crackles Rt Lt
Sputum
None Productive Non-productive

For critical patients Whitish Yellowish Brownish Greenish

Thick Frothy Bloody Blood tinged

Intubated Tracheostomy BIPAP CIPAP

Parameters: Mode _________ RR ________ TV ________ FiO2 PEEP ______

Blood: ________ mmHg Heart Rate: _______ b/min

Heart Rhythm
Regular Irregular
Heart Sounds
S1 S2 other: (S3, S4, Murmur, Valvular Click, Etc)
Capillary refill
Normal (3) Delayed: _____ sec
Peripheral Pulses/
Edema Peripheral Pulses Edema
Cardiovascular Strength* No Yes Non-
Pitting
Pitting Grade*

Brachial R L Hands R/L

Radial R L Abdomen R/L
Femoral R L Knees R/L
Popliteal R L Legs R/L
Tibial R L Ankle R/L
D. Pedis R L Scrotum R/L
Strength*: Absent (0), Thready (+1), Weak (+2), Normal (+3), Bounding (+4)
Intravenous Access Grade*: Quickly disappears(1), disappears in 10-15sec (2), 1-2 min (3), >2 min (4)

Peripheral Central Polysite Site: ______________

 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

VIII. Physical Assessment:

Diet: _______________ Nutritional Intake: Adequate Inadequate
Oral Mucosa
Intact Moist Dry Pink Pale
Tongue
Intact Cracked Swollen White Patches

Nausea: Yes No Vomiting: Yes No

Abdomen
Bowel Sounds Soft Tender Distended Hard Ascites

Gas- tro Active in all quadrants

Absent Hyperactive Hypoactive Location: __________
Inte stin
Bowel al
Pattern

Tube/Stoma
Normal Diarrhea Constipation Incontinence
Last Bowel Movement: _____________ Stool Color: _____________

None N/G tube Gastrostomy Colostomy Others: ______

Assessment of Urethra Normal Urethral Abnormalities Urethral Discharge

Assessment of Vagina Normal Vaginal Discharge

Assessment of
Normal Burning Frequency Urgency
Urination
Bladder Distension Pelvic Pain Flank Pain

Genitourinary
Voiding
Freely Foley Catheter Urostomy CBI
Urine Output Continent Incontinence Dialysis Others: __________

Urine Color Normal Polyuria Oliguria Anuria

Yellow Orange Pink Red tinged

Urine Characteristics Grossly Bloody Amber Dark Amber

Clear Cloudy Sediment Abnormal Odor

 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

I. Physical Assessment:
Pain No Pain
Tool Used
Pain VDS/VAS Faces Behavioral CPOT
Provoke
What initiates the pain: _____________ What aggravates it: __________
Quality Are you on pain management: ______ What relieves it: ___________

Character: ______________
(Sharp, dull, stabbing, burning, throbbing, twisting, stretching, etc)
Region/Radiation
Location: __________________ Radiate to: ________________
Severity
Scale: _______/10
Time
Duration: __________________ Frequency: ________________
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Normal Pale Jaundice Cyanosis

Skin Color
Warm Hot Cool Cold
Skin Temperature

Intact or with
Skin Is Ecchymosis Hematoma Lesion/ Laceration Palpable mass
Pressure Ulcer: Location: _________ Stage: ________ Color:
______
Length: ____ Width: _____ Depth: _____ Slough/Eschar

Pressure Ulcer management: _____________________________

Integumentary
Wound Assessment Normal
Redness Swelling Tenderness Dehiscence

Discharge None
Bloody Purulent Serous Serous-sanguineous Biliary Odorous

Amount Minimal Moderate Excessive

Surg ical Wound

Drainage None Yes
Penrose Jackson-Pratt Hemovac Vacuum Drainage

Nursing Note
Lebanese University
Faculty of Public Health V
Nursing Sciences Department
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

IX. Medications:
Drug 1. 2. 3. 4.
(Brand Name)

Generic Name

Classification

Route & Dosage

Ordered
(PRN/Stat/Standing)
Mode of Action

Indications

Contraindication

Nursing
Considerations
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

IX. Medications:
Drug 5. 6. 7. 8.
(Brand Name)

Generic Name

Classification

Route & Dosage

Ordered
(PRN/Stat/Standing)
Mode of Action

Indications

Contraindication

Nursing
Considerations
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

X. Nursing Diagnosis:
Nursing Nursing Diagnosis Expected Outcome Nursing Interventions Evaluations
Diagnosis Related to
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

X. Nursing Diagnosis:
Nursing Nursing Diagnosis Expected Outcome Nursing Interventions Evaluations
Diagnosis Related to
Lebanese University
Faculty of Public Health V
Nursing Sciences Department
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

. Daily Plan:
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

I. Disease or Condition Research:

1. Name of Disease/definition/pathophysiology:

2. Signs and symptoms are:

3. Medical or surgical care & treatment:

4. Diagnostic tests for this disease (include lab & X-Rays, etc.):
 Lebanese University
Faculty of Public Health V
Nursing Sciences Department

5. Nursing Care for this disease (include examples of diet):

6. Teaching with discharge planning (include S/S to report to doctor):