assessment form (bsu)

8/6/2019 Assessment Form (BSU)

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BUKIDNON STATE UNIVERSITY

COLLEGE 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/NUTRITION

Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.Objective Subjective

General Appearance: Alert/responsive

Apathetic Cachexia Abdominal Distention

Mass Tenderness/pain

Skin: 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: Yes None

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 No

Undesired 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 ConstipationFrequency of BM:______________/day

Remarks: _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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Nursing Diagnosis:

_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

B. RESPIRATORY SYSTEM

Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort

Objective Subjective

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 Biots

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-productive

Sputum: Mucoid Bloody (hemoptysis)

Rusty Frothy Thick TenaciousColor: ____________________________

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: _________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Nursing Diagnosis:

_________________________________________________________________________________________

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_________________________________________________________________________________________

_

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


Temperature: _______________Celsius

Blood Pressure: Right_______ Left ___________

Pulses:Carotid Pulse: Thready Weak Strong/bounding

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 Sounds:____________

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 Pitting

Location: _____________________________

Varicosities: Yes NoLocation: __________________________________

Calf Tenderness (Homans 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

Numbness and Tingling

Light headedness Fatigue and weakness

PalpitationsComment: ___________________________________

__________________________________________________________________________________________

Exercises:

Type: _______________________________________

Frequency: __________________________________

Duration: ____________________________________

Problem experience with usual activity and exercise:

Comment: ____________________________________

_____________________________________________

Factors Affecting Activity Intolerance:

Comment: ____________________________________

_____________________________________________

Remarks: _________________________________________________________________________________

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5/19

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Nursing Diagnosis:

_________________________________________________________________________________________

__________________________________________________________________________________________

_

D. INTEGUMENTARY SYSTEM

Note: 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 Onycholysis

Capillary refill: __________ (Normal less than 2 sec)Color: _________________

Comment : ___________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Comment:____________________________________

_____________________________________________

_____________________________________________

Comment:____________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Remarks: _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Nursing Diagnosis:

_________________________________________________________________________________________

_

__________________________________________________________________________________________

_________________________________________________________________________________________

_

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E. ELIMINATION


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: _________________

_____________________________________________

Personal Elimination Habits:____________________

_____________________________________________

Elimination Problem:

Loose bowel movement _________

Constipation Impaction Fecal Incontinence

Neurologic Impairment Dysuria Urgency Polyuria Oliguria Nocturia Dribbling

Incontinence Hematuria Retention

Discharge

Urinary Elimination changes _________________

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:

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7/19

Yes No

Consistency:

Stools: ______________________________________

Remarks: _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Nursing Diagnosis: _________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

__

F. MUSCULOSKELETAL SYSTEM

Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.


Mobility: Ambulatory Non Ambulatory

Bedridden Appliance __________________________

Gait and Posture: Lordosis Kyphosis

Scoliosis Shuffling Poliomyelitis

Amputated Limb ______________________

Club foot (Talipes)

Varus Valgus Equinovarus Calcanous

Muscle Tone/Strength:

Normal Slight weakness Average weakness Poor ROM

Severe Weakness Paralysis

Atrophy Hyperatrophy

Spasm

Abnormal Findings:

Impaired ROM Joint swelling ____________


Lumbar pain Thoracic Pain Cervical Pain Joint painComment ____________________________________

_____________________________________________

_____________________________________________

Comment: ___________________________________

_____________________________________________

Comment: ___________________________________

_____________________________________________Comment: ___________________________________

_________________________________________________________________________________________

_____________________________________________

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8/19

Contractures/Deformities Crepitus

Tingling/Numbness (Carpal Tunnel Syndrome)

Ankylosis Foot Drop Pressure Ulcers

Calf Tenderness (Homans Sign):

Right Positive Negative

Left Positive Negative

Comment: ___________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Remarks: _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________


_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,


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9/19

LOC: Alert Lethargic Comatose

Unresponsive Obtunded Stupor

GCS Score:_________

Cushing Triad (Respiratory changes, Increase BP,

Decreasing level of Consciousness)

Positive Negative

Sensation: Positive Negative

Pupillary Size: PERRLMAE Anisocoric

Orientation: Person Place Time/Date

Pain

Sensory Function: Positive NegativeLocation: __________________________________

Motor Function: Positive NegativeLocation: __________________________________

Vital Signs: BP: ______ T______P_____R______

Brudzinskis sign: Positive Negative

Kernigs Sign: Positive Negative

Decorticate: Positive Negative

Decerebrate: Positive Negative

Reflexes:

Patellar Positive Negative

Biceps Positive Negative

Triceps Positive Negative

Achilles Positive Negative

Check the Following Risk Factors:

Older Adulthood Male Hx Stroke or TIA

Hypertension Smoking Hx CVD

Sleep Apnea High level of Cholesterol

Drug Abused DM Oral Contraceptives

Menopausal Over weightComment: ____________________________________


Blurring Diplopia Photophobia

pain Inflammation Cataract

Glaucoma Headache Unusual DischargesComment: ____________________________________

_____________________________________________

Remarks: _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

_________________________________________________________________________________________

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10/19

GLASGOW COMA SCALEPatient Name: ____________________________ Date:_________________

Rater Name:____________________________

Activity Score

EYE OPENING

None 1 = Even to supra-orbital pressure

To pain 2 = Pain from sternum/limb/supra-orbital pressure

To speech 3 = Non-specific response, not necessarily to command

Spontaneous 4 = Eyes open, not necessarily aware _______

MOTOR RESPONSE

None 1 = To any pain; limbs remain flaccid

Extension 2 = Shoulder adducted and shoulder and forearm internally rotated

Flexor response 3 = Withdrawal response or assumption of hemiplegic posture

Withdrawal 4 = Arm withdraws to pain, shoulder abducts

Localizes pain 5 = Arm attempts to remove supra-orbital/chest pressure

Obeys commands 6 = Follows simple commands _______

VERBAL RESPONSE

None 1 = No verbalization of any type

Incomprehensible 2 = Moans/groans, no speech

Inappropriate 3 = Intelligible, no sustained sentences

Confused 4 = Converses but confused, disoriented

Oriented 5 = Converses and oriented _______

TOTAL (315):_______

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III. LABORATORY AND DIAGNOSTIC EXAMINATION

Date

Ordered

LABORATORY AND

DIAGNOSTICResult Significance

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12/19

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

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14/19

V. DRUG STUDYName of Drug

Generic

(brand)

Classification

Dose/

Frequency/

Route

Mechanism of

actionIndication Contraindication Side effects Nursing Precaution

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VI. SOAPIE (First day)

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VI. SOAPIE (Second day)

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VI. SOAPIE (Third day)

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VII. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

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VII. PATHOPHYSIOLOGY

Name of Patient: __________________________________ Age: ______________ Sex _________________

Diagnosis: ________________________________________________________________________________

Definition:

Reference:

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assessment form (bsu)

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