bsu college of nursing assessment form
TRANSCRIPT
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BUKIDNON ST ATE UNIVE RSITYCOLLEGE 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:
__________________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________________
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_________________________________________________________________________________________
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Has received blood in the past? Yes _____ No ______ if yes, list dates_________________
Blood reactions if any: ______________________________________________________________________
__________________________________________________________________________________________
Allergies:
Food: ______________________________________________________________________________Medications: _________________________________________________________________________
Admitting Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________
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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: 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 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:
_________________________________________________________________________________________
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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: _________________________________________________________________________________
__________________________________________________________________________________________
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Nursing Diagnosis:
_________________________________________________________________________________________
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_________________________________________________________________________________________
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C. CARDIOVASCULAR/CIRCULATORY SYSTEMNote: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective Subjective
Temperature: _______________Celsius
Blood 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 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
Cough 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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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Nursing Diagnosis:
_________________________________________________________________________________________
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D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective Subjective
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 : ___________________________________
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Comment:____________________________________
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Comment:____________________________________
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Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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E. ELIMINATION
Objective Subjective
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: ________________________________________________________________________________
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___________________________________________
___________________________________________Excessive Perspiration and Odor Problem:
Yes No
Consistency:
Stools: ______________________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
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F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.
Objective Subjective
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 ____________
Do you experience any of the following:
Lumbar pain Thoracic Pain Cervical Pain
Joint painComment _________________________________________________________________________________
_____________________________________________
Comment: ___________________________________
_____________________________________________
Comment: ___________________________________
_____________________________________________
Comment: ___________________________________
_________________________________________________________________________________________
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Contractures/Deformities Crepitus
Tingling/Numbness (Carpal Tunnel Syndrome)
Ankylosis Foot Drop Pressure Ulcers
Urinary Elimination changes _________________
Calf Tenderness (Homans Sign):
Right Positive Negative
Left Positive Negative
Comment: ___________________________________
__________________________________________________________________________________________
_____________________________________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
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____________________________________________________________________________________________________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
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G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC
Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,
Objective Subjective
LOC: Alert Lethargic Comatose
Unresponsive Obtunded Stupor
Decorticate Decerebrate
GCS Score:_________
Cushing Triad (Respiratory changes, Increase BP,Decreasing level of Consciousness)
Positive Negative
Sensation: Positive Negative
Pupillary Size: PERRLA Anisocoric
Orientation: Person Place Time/Date
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 weight
Comment: ____________________________________
Do you experience any of the following:
Blurring Diplopia Photophobia
pain Inflammation Cataract
Glaucoma Headache Unusual DischargesComment: ____________________________________
_____________________________________________
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Pain
Sensory Function: Positive NegativeLocation: __________________________________
Motor Function: Positive NegativeLocation: __________________________________
Vital Signs: BP: ______ T______P_____R______
Brudzinskis sign: Positive Negative
Kernigs Sign: Positive Negative
Reflexes:
Patellar Positive Negative
Biceps Positive Negative
Triceps Positive Negative
Achilles Positive Negative
Remarks: _________________________________________________________________________________
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Nursing Diagnosis: _________________________________________________________________________
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III. LABORATORY AND DIAGNOSTIC EXAMINATION
Date
Ordered
LABORATORY AND
DIAGNOSTICResult 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
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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