Cebu Normal UniversityCollege of Nursing

Cebu CityMission-Vision: “Care Using Knowledge and Compassion”

ASSESSMENT FORM

I. Biographic Data, Chief Complaint, HPI

Client’s Initials: ______________________Age :_______ Gender:_________Religion:____________Civil Status: ______________Allergies:____________________________________________________ Diet: _________________________ Height: ____________________Weight: _____________________Date & time of Admission:_____________________ Mode of Admission: _______________________Impression/Diagnosis:__________________________________________________________________Reason for seeking health care: _________________________________________________________Vital Signs: T:_________ PR:________ RR:________ BP: _________ Pain score:___________________General Physical Description:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________General Behavior exhibited:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Physician in-charge:_________________________________Nurse-on-Duty: _____________________________________

Client’s Complaints Upon Admission________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

History of Present Illness____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. Physical Examination1. Intrapersonal

a. Physiological (Head to Toe)Past medical history:

Illnesses:____________________________________________________________________________ Surgery:____________________________________________________________________________ History of chronic disease_____________________________________________________________

Immunization History: (specify the number of doses received) _____ BCG _____ DPT _____ OPV _____ AMV _____ MMR _____ HepB _____ TT _____ HiB _____ MMV _____ Rubella Vaccine _____ Others(specify)

Smoking:_____ pcks/day_____ pck/year

Alcoholic Beverages:______________Type ______________ Amount______________ Frequency of Use ______________ Date of Last Drink

Illicit drugs: ______________Type ______________ Amount______________ Frequency of Use ______________ Date of Last Use

Medication (prescription/OTC)

Medicine Dose Frequency Last Dose Indication

Allergies: ______________ Foods ______________ DrugsPerception of health: _____ good _____ fair _____ poor Dietary Preferences: _________________________________________________________________

Physical Assessment:Central Nervous SystemLevel of Consciousness:

_____alert _____lethargic _____drowsy_____Obtunded _____Stupurous _____Comatose

Mood (subjective):_____ pleasant _____irritable _____calm_____happy _____euphoric _____ anxious_____ fearful _____ others(specify)

Affect (objective):_____surprise _____anger _____sadness_____joy _____disgust _____fear_____flat _____blunted _____full

Orientation Level:_____person _____place _____time

Memory:_____ recent _____Intermediate _____Remote

Pupils: Right Left_____size _____Reaction _____size _____Reaction

Reflexes:_____ grade (describe)

Grasps: Right Left_____Strong _____Weak _____Strong _____Weak

Others:_____Numbness _____Tingling _____Restless _____ Mannerism

Pain: None: _____Provoking/Precipitating factors:________________________________________________

Quality/Location:______________________________________________________________ Radiating or non-radiating:_____________________________________________________

Severity/intensity: _____________________________________________________________Timing:_______________________________________________________________________

Visual Acuity:_____Normal _____glasses _____ contacts_____blind (R/L) _____Prosthesis: (artificial eye) R/L

Hearing:

_____Normal _____impaired (R/L) _____deaf(R/L)_____hearing aid _____tinnitus _____drainage from ears

Touch:_____Normal _____abnormal (specify)

Smell:_____normal _____abnormal

Communication:_____ Broca’s Aphasia _____ Wernicke’s Aphasia_____ Global Aphasia

Cardiovascular System Pulse Rate and Characteristics:

_____regular _____irregular _____strong _____weak _____ Right Upper Extremity _____ Left Upper Extremity_____ Right Lower Extremity _____ Left Lower Extremity

Heart Sounds: _____ S1 _____S2 _____Others (specify)Blood Pressure: _____ standing _____lying _____sitting Extremities: Temperature:

Upper Extremities _____cool _____warm Lower Extremities _____cool _____warm

Capillary Refill Time: _____ second/s Homan's Sign: _____ Negative _____Positive

Claudication: _____ Negative _____Positive Nails: _____Normal _____Thickened

_____Clubbing _____Other (specify)

Respiratory System Chest: _____ symmetrical _____ asymmetrical (specify)Respirations: _____ rate

_____ depth (shallow/deep, abdominal/diaphragmatic) _____ regular _____ irregular (specify)

_____ periods of apnea _____ dyspnea at rest_____ orthopnea_____ dyspnea on exertion _____others(specify)

Cough: _____ absent _____ present (specify)_____ dry_____soft_____ productive _____ nonproductive_____ whooping

_____ Sputum: _____odor_____color_____consistency

Breath Sounds:_____ Normal _____ Adventitious (specify location)

_____ absent_____ crackles_____ rhonchi _____ friction rub_____ wheezing

Respiratory devices: _____ CTT:___________________________________________________________________ Tracheostomy: _________________________________________________________ ETT:___________________________________________________________________Oxygen Therapy: __________________________________________________

Gastrointestinal SystemPrescribed Diet: _________________________________________________________________ Appetite: _____Normal _____Abnormal (specify)Gag Reflex: _____ Present _____ Absent

GIT problems: _____ Nausea _____Vomiting _____ Dysphagia _____ Constipation

_____ Diarrhea _____Incontinence_____ hemorrhoids _____ Others (specify)

Feeding Ability: _____ Able _____ Unable (specify)Mouth: _____pink _____inflammed

_____moist _____dry _____lesions/ulcerations _____ Others(specify)

Oral Prosthesis: _________________________________________________________________Defecation Pattern: _____ Consistency _____ Color

_____ Amount _____ FrequencyAbdomen: _____symmetry _____ flat

_____rounded _____obese_____Ascites _____Soft_____Firm _____ Tender_____ Distended

Bowel sounds: _____Hypoactive _____ Hyperactive _____Normoactive _____Absent

Bowel Diversions: _____ Ostomies (specify)

Integumentary System

____ color: pallor, ashen, pink, jaundice, cyanotic, ruddy ____ temperature: warm, cool ____dry, moist, clammy, diaphoretic

____Skin integrity: intact, impaired (specify) ____turgor: good, poor

____edema:pitting/non-pitting, dependent, bipedal, periorbital, anasarca ____pruritus ____bruises/lesions

____decubitus ulcer(describe)

Urinary System

Bladder Patterns: _____ color _____ Amount_____ Turbidity _____ Frequency

Urinary problems: _____Dysuria _____Nocturia_____Urgency _____Hematuria _____Retention _____Burning_____Hesitancy _____ Incontinence

Elimination Assistive Devices:_____ catheterization (specify)

Musculoskeletal System

Self-Care Ability: (0=Independent 1=Assistive device 2=Assistance from others 3=Assistance from person and equipment 4=Dependent/Unable)

Self care

0 1 2 3 4 Self care 0 1 2 3 4

Feeding Transferring

Bathing AmbulatingDressing

Toileting

Bed Mobility

Problems: _____ tremors _____ atrophy _____ swelling Assistive Devices: _____none _____crutches _____Commode

_____Walker _____cane _____splint/brace _____wheelchair _____others (specify)

Gait: _____normal _____abnormaI (specify)

Range of Motion:_____normal _____limited (specify)

Posture:_____normal _____Kyphosis_____Lordosis _____Scoliosis

Deformities: _____None _____Yes (specify) Amputation: _____None _____ Yes (specify)

Reproductive SystemSexual concerns:_____________________________________________________________________ _____________________________________________________________________________________Female: _____LMP _____GPTPAL Score

_____Menopause (specify) Family Planning: _____No _____Yes (type)

Vaginal bleeding: _____No _____Yes (describe)History of sexually transmitted disease _____None _____Yes(specify) Last Pap Smear: _________

Male: Prostate problems _____No _____Yes (type) Penile discharges: _____No _____Yes (type Last prostate exam:_______Congenital Problems:

_____hypospadia _____epispadiaHistory of sexually transmitted disease _____None _____Yes(specify)

b. Psychological

Overt signs of stress: (crying, wringing of hands, clenched fists) Coping Strategies:___________________________________________________________________Impact of Hospitalization/Illness (financial, self-care, role performance):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recent Major loss: ___________________________________________________________________Living Arrangement:

_____ Alone _____Nuclear _____ Extended Number of Children: __________________Occupation:_________________________________________________________________________Employment Status:

_____employed _____ unemployed _____unemployed Social activities:

_____active _____limited _____none

c. Spiritual

Religion: _____Protestant _____Catholic _____Jewish _____Muslim _____Buddhist _____others(specify)

Religious Practices/Restrictions:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Concerns related to spiritual or religious customs? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

d. Developmental

Psychosocial tasks: ______________________________________________________________________________________________________________________________________________Psychosexual task:

_______________________________________________________________________Cognitive level:

_______________________________________________________________________

Moral Development:

_______________________________________________________________________

2. Interpersonal (between persons) and Extrapersonal (within the community)

a. Socio-culturalCommunity participation: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health cultural beliefs:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Political Affiliations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Stressors as perceived by the nurse: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VI. Nursing Care Plan

a. NURSING DIAGNOSES (in priority)Classification Nursing Problems (at least 5)Physiological

Psychological

Socio-cultural

Spiritual

Developmental

b. Discharge PlanningClient’s Initials:Diagnosis:Probable Date:Destination:Transportation:Medications

Environment & Exercise

Treatments

Health Education

Observable symptoms

Dietary Prescription

Spirituality