assessment tools

BUKIDNON STATE UNIVERSITYCOLLEGE OF NURSING

ASSESSMENT TOOLS

I. DATA BASE AND HISTORY

Name of Patient: ___________________________Date of Birth: ______________ Sex: ______ Age: _______Address: __________________________________________________________________________________Religion: _______________________________ Civil Status: _______ Nationality: ______________________Date of Admission: _______________________ Time of Admission: _________________________________Informant: ______________________________ Relation to Patient: __________________________________Address of Informant: _______________________________________________________________________

Initial vital signs:Temperature: _________ Pulse Rate: ________ Respiratory Rate: _________ Blood Pressure: _____________

Chief Complaints and History of Present Illness:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has received blood in the past? Yes _____ No ______ if yes, list dates_________________

Blood reactions if any: ________________________________________________________________________________________________________________________________________________________________

Allergies:Food: ______________________________________________________________________________Medications: _________________________________________________________________________

Admitting Diagnosis: __________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Attending Physician: _________________________________________________Consultant: _________________________________________________________

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II. NURSING ASSESSMENT

A. DIGESTIVE/METABOLIC/NUTRITIONNote: Assess for bowel habits, swallowing, bowel sounds, comfort.

Objective Subjective

General Appearance: □ Alert/responsive□ Apathetic □ Cachexia □ Abdominal Distention□ Mass □ Tenderness/painSkin: □Dry □Warm □Cold □Moist □EdemaTurgor: ____________________________________

Eyeball: □ Sunken □ Moist □Dry

Mouth: □ Dentures □ Braces □ Lesions □ Cleft Palate □ Cleft Lip □ UlcersNo. of teeth: ______________________Tongue: □ Dry □ Moist □ Furrows

Venous filling: ________ (Normal less than 3-5 sec)

Intravenous Fluid: __________________________Date of insertion: ____________________________

Wounds: __________________________________

Tube/Drainage: _____________________________

Vital Signs: T _____ P ______ R_______BP ______

Body Types:□ Ectomorph □ Mesomorph □ Endomorph□ Obese □ Thin

Loss of Appetite: □ Anorexia □ Bulimia Body weight: _____________kg

Usual Diet: ___________________________________No. of meals per day: ___________ (3x a day)No. of fluid drink each day: _______(8-12 glasses/day) □ Alcohol and Beverages ________________________

Undesired Weight loss: □ Yes □ NoUndesired Weight gain: □ Yes □ No

Food restrictions R/T intolerance and health problems or religious practices? __________________________________________________________________________________________

Difficulty in eating and swallowing: __________________________________________________________________________________________

Previous/Recent Illness:□ Diabetic □ Hyperthyroidism □ Hypothyroidism □ Colon Cancer □ Abdominal PainComment: _____________________________________________________________________________________________________________________________

Elimination pattern: □ Diarrhea □ Constipation Frequency of BM:______________/day

Remarks: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis:____________________________________________________________________________________________________________________________________________________________________________________

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B. RESPIRATORY SYSTEMNote: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort


Breath Sounds: □ Diminished/Absent □ Stridor □ Rales/Crackles □ Rhonchi/Wheezing □ Normal (Vesicular, Bronchovesicular, Bronchial)□ None (atelectasis)

Resonance: □ Hyper □ Hypo

Respiration/Oxygenation:□ Normal(Relax, Effortless and Quiet)□ Labored/Use accessory Muscle] □ Dyspnea□ Tachypnea □ Bradypnea □ Cyanosis □ Pallor □ Cheyne-stoke □ Biot’s □ Hyperventilation □ Hypoventilation □ Nasal Flaring □ Pursed lip □ Barrel Chest □ Pleuritic Pain □ O2 Inhalation _____liters/minRate: ________________________Tube/Drainage: □ CTT □ Oral Airway □ Endotracheal Tube □ Ventilator

Cough: □ Productive □ Non-productiveSputum: □ Mucoid □ Bloody (hemoptysis)□ Rusty □ Frothy □ Thick Tenacious Color: ____________________________

Previous/Recent Illnesses:□ Bronchitis □ Emphysema □ Asthma □ Brochiectasis □ Pneumonia □ Hydrothorax □ Pneumothorax □ Hemothorax □ CHF □ Chest Trauma □ Lung CancerComment: ___________________________________________________________________________________________________________________________________________________________________________

Breathing Treatments/Medication: _____________________________________________________________________________________________________________________________________________________

Smoking: □ Yes For how long: __________□ NoComment:________________________________________________________________________________________________________________________________________________________________________________________________________________________

Remarks: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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C. CARDIOVASCULAR/CIRCULATORY SYSTEMNote: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.


Temperature: _______________ CelsiusBlood Pressure: Right_______ Left ___________

Pulses: Carotid Pulse: □ Thready □ Weak □ Strong □ Absent Rate: Right______Left______

Apical: □ Regular □ Irregular Rate: ____

Radial Pulse: □ Regular □ Irregular □ Thready □ Weak □ Strong □ Absent Rate: Right______ Left _______

Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak □ Strong □ Absent Rate: Right_____ Left _____Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak □ Strong □ Absent Rate: Right_____ Left _____

Heart Rhythm: □ Tachycardia □ Bradycardia□ Arrhythmia/ Dysrhythmia

Jugular Veins Distention:□ Positive □ Negative

Nail bed Color : □ Pink □ Blue □ Pale

Capillary Refill: ________ (Normal less than 2 sec)

Edema: □ Pitting □ Non PittingLocation: _____________________________

Varicosities: □ Yes □ NoLocation: __________________________________

Calf Tenderness (Homan’s Sign):Right □ Positive □ Negative Left □ Positive □ Negative

Previous/Recent Illness:□ CVA □ CHF □ MI □ Thrombophlebitis□ Family History of HPN □ Renal Failure □ Bleeding Disorder __________________________Comment: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you experience any of the following:□ Chest pain □ Arm pain □ Leg pain□ Joint and Back □ Dyspnea □ Orthopnea □ Cough □ Numbness and Tingling□ Light headedness □ Fatigue and weakness□ Palpitations Comment: _____________________________________________________________________________________________________________________________

Exercises:Type: _______________________________________Frequency: __________________________________Duration: ____________________________________

Problem experience with usual activity and exercise:Comment: _________________________________________________________________________________

Factors Affecting Activity Intolerance:Comment: _________________________________________________________________________________

Remarks: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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D. INTEGUMENTARY SYSTEMNote: Assess skin integrity, color, temperature, turgor, hair distribution, nails.


Skin: □ Dry □ Intact □ Warm □ Cold □ moistTurgor:_____________________________________ □ Pallor □ Cyanosis □ Jaundice □ Rashes□ Acanthosis Nigricans □ Albinism □ Erythema□ Edema □ Petechia □ Itching □ Drainage □ Swelling □ Wound □ Ecchymosis/hematoma□ Decubitus UlcerTemperature: _________

Hair: □ Alopecia □ Hirsutism □ Patchy hair lossDistribution: ________________________________

Nails: □ Dirty □ Pallor □ Cyanosis□ Clubbing □ Paronychia □ OnycholysisCapillary refill: __________ (Normal less than 2 sec)Color: _________________

Comment : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Comment:______________________________________________________________________________________________________________________________

Comment:___________________________________________________________________________________________________________________________________________________________________________

Remarks: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis:

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E. ELIMINATION


Mobility and Dexterity: □ Ambulatory □ Non-ambulatory□ Bedridden □ with assistive device

Tubes/Drainage/Stoma:□ Colostomy □ Ileostomy □ NGT□ Catheter □ Suprapubic Catheter

Abdomen: □ Soft □ Firm □ Distended □ Non-distended

Bowel Sounds: (5 – 20 sounds/min)□ Normoactive □ Hypoactive□ Hyperactive(Borborygmi) □ Absent

Measurement:Intake ____________ Output:_______________

Edema: □ Yes □ NoLocation: __________________________________

Present Urine Color: ________________________

Note: Assess urine frequency, color, odor control, comfort/gyn-bleeding, discharge.

Comment: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Previous/Recent Surgery/Illness: _____________________________________________

History of pain and discomfort: ______________________________________________________________

Diet: ________________________________________

Personal Elimination Habits:_________________________________________________________________

Elimination Problem:□ Loose bowel movement _________□ Constipation □ Impaction □ Fecal Incontinence□ Neurologic Impairment □ Dysuria □ Urgency□ Polyuria □ Oliguria □ Nocturia □ Dribbling□ Incontinence □ Hematuria □ Retention□ Discharge□ Residual urine (> 100ml)Comment: ________________________________________________________________________________

Medication taken: □ Analgesic Narcotic□ Antibiotics □ Anticholinergic □ NSAID□ Aspirin □ H2 antagonist

Fluid intake per day: __________ liters/day

Physical Activity: _____________________________Comment: ________________________________________________________________________________Excessive Perspiration and Odor Problem:□ Yes □ No

Consistency:Stools: ______________________________________

Remarks: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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F. MUSCULOSKELETAL SYSTEMNote: Assess mobility, motion, gait, alignment, joint function, muscle tone, comfort.


Mobility: □ Ambulatory □ Non Ambulatory□ Bedridden □ Appliance __________________________Gait and Posture: □ Lordosis □ Kyphosis □ Scoliosis □ Shaftling □ Poliomyelitis□ Amputated Limb ______________________

Club foot (Talipes)□ Varus □ Valgus □ Equinovarus □ Calcanous

□ Use of Appliance __________________________ Muscle Tone/Strength:□ Normal □ Slight weakness □ Average weakness □ Poor ROM □ Severe Weakness □ Paralysis□ Atrophy □ Hyperatrophy □ Spasm

Abnormal Findings:□ Impaired ROM □ Joint swelling ____________□ Contractures/Deformities □ Crepitus □ Tingling/Numbness (Carpal Tunnel Syndrome)□ Ankylosis □ Foot Drop □ Pressure Ulcers□ Urinary Elimination changes _________________

Calf Tenderness (Homan’s Sign):Right □ Positive □ Negative Left □ Positive □ Negative

Do you experience any of the following:□ Lumbar pain □ Thoracic Pain □ Cervical Pain □ Joint pain Comment ______________________________________________________________________________________________________________________________

Remarks: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC Note:


LOC: □ Alert □ Lethargic □ Comatose □ Unresponsive Orientation: □ Person □ Place □Time/Date □ Pain

Do you experience any of the following: □ Blurring □ Diplopia □ Photophobia □ pain □ Inflammation □ Cataract □ Glaucoma □ Headache □ Unusual DischargesComment: _________________________________________________________________________________

Remarks: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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III. LABORATORY AND DIAGNOSTIC EXAMINATION

Date Ordered

Procedure Result Significance

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IV. NURSING CARE PLANDATA NURSING DX OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

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V. DRUG STUDYName of Drug

Generic (brand)

Classification Dose/ Frequency/

Route

Mechanism of action

Indication Contraindication Side effects Nursing Precaution

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VI. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

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VII. CONCEPT MAPPING

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