STI College of Nursing CDO

1. Cagayan De Oro City
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 AND METABOLIC 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
Range of 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
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7. PATHOPHYSIOLOGY
PREDISPOSING FACTORS: PRECIPITATING FACTORS:
________________________________________________ _____________________________________________
________________________________________________ _____________________________________________
________________________________________________ _____________________________________________

8. DIAGNOSTIC STUDIES AND LABORATORY RESULTS
Note: Place all the diagnostic studies done to the patient and indicate only significant results.

9. DISCHARGE PLAN
Medications
Exercise
Treatment
Health Teaching
Out patient
check up
Diet
Spiritual

10. Cagayan de Oro City
Bachelor of Science in Nursing
HOSPITAL ROTATION
MANUAL
__________________________________
AREA OF ROTATION
Clinical Instructor:
_____________________________
Florig, Sharmaine Grace B.
Name of Student