Cagayan de Oro City

COLLEGE OF NURSING
ASSESSMENT FORM
GENERAL INFORMATION
Patients Name:
Patient X
Age : 32yrs.old
Sex:
___Female
Address: __Zone 10, Zayas, Cagayan de Oro City
Status:
_married
_____
Religion:Roman Catholic__
Educational Attainment: _ High School graduate
Occupation:
______housewife___________________________
Nationality: __Filipino_________ _______________
Income:____________N/A__
_______________________
Name of Spouse/Guardian: __XXX___________________
Contact
Number:
___N/A____________________________
Date of Admission (MM/DD/YY): ___September 4,2012____________
Time of Admission :
____10: 00 AM__________
Baseline Vital signs: BP: _______80 / 50mmHg________ _
T: _36.3C
_ PR: ___104 bpm___
RR: _ 42 cpm _
Weight upon admission (in Kg): _______N/A________________
Height
(in
ft
&
in):
______N/A________________
CHIEF COMPLAINTS
Vaginal Bleeding
HISTORY OF PRESENT ILLNESS
Four Days Prior to Admission, Patient noted vaginal bleeding but she was not alarmed.
So, she doesnlt seek medical assistance. The day Prior to admission,The patient notice continous flow
of blood with fetus and she was immediately brought to Northern Mindanao Medical Center .
DATE OF ADMISSION
September 4,2012

NAME OF INSTITUTION
Northern Mindanao Medical Center

HOSPITALIZATION HISTORY
ALLERGIES:
Yes
No
Food: _____________________
_____________________

(If yes, specify below)

Medications: _________________________ Others:

BLOOD TRANSFUSION HISTORY: Yes

BLOOD TYPE: _O__
DATE OF TRANSFUSION
September 4,2012

DIAGNOSIS/INDICATION
Incomplete Abortion

No

(If yes, indicate below.)

INDICATION
For blood Loss

REACTION
None

MEDICATION HISTORY (Previously taken, maintenance, current, etc.) N/A

DRUG NAME
DATE TAKEN
SCHEDULE

INDICATIONS

LABORATORY EXAMS/IV FLUIDS

Date
Diagnostic /
Date
ordered
Laboratory exams
done
(mm/dd/y
(mm/dd/
y)
yy)
9l4l12
Hematology
9/2/12
9/5/12
Ultrasound
9/5/12
9/5/12
Hematology
9/5/12
9/5/12
ABG
9/5/12

Date
ordered
(mm/dd/
yy)
9/4/12
9/4/12
9/5/12
9/5/12

IV fluids/blood

Date discontinued
(mm/dd/yy)

PNSS 1 L fast drip

PNSS 1 L@20gtts/min
Dopamine drip 54cc/hr
D5W+150NaHCO3
meq.@20cc/hr

Have you been taking your medication(s) as prescribed?

Yes

No

A. NUTRITION AND METABOLIC PATTERN

Special diet:
Yes _____ (specify) __________________________________
Supplements: Yes _____ (specify) __________________________________
Nutritional state:
Well-nourished __/___
Poorly nourished _____
Cachexia _____
Mouth:
Lips
Mucosa
Tongue
Pinkish

_____

Pinkish

_____

Midline

9/4/12

No ___/_
No ___/_
Obesity

_____
Teeth

__/___

Complete

_____
Pallor
__/___
Caries
_____
Cyanosis
_____
teeth___/__
Lesions
_____
Dentures
_____
Dryness/cracks _____
Gums
Pinkish
_____
Tenderness _____
Pharynx:
Uvula
Midline
___/__
R/L deviation _____

Pallor

__/___

Cyanosis _____

Atrophy

_____

Fasciculation _____

Missing

R/L deviation _____

Pallor
Mucosa
Pinkish ___/__
Pallor
Reddish _____

__/___

Bleeding

_____

Tonsils
Not inflamed __/___
_____
R/L Deviation _____
R/L Exudates _____

Neck:
Trachea
Others: N/A
Midline
__/___
R/L deviation __/___
Neck enlargement ____
_Lymphadenopathy
_____ Tenderness _____
ROM
_____
Cervical Lymph Nodes _____
_____
Skin:
General Color
Texture
Pinkish
_____
Smooth
__/___
Dry
__/___
Cyanotic
_____
Rough
_____
Moist/Clammy
_____
Pallor
___/__
Others:
Flushed
_____
_______________
Jaundiced
_____
Mottled
_____
Dusky
_____

Thyroids
Non-palpable __/___
Enlarged

_____

Normal
Neck

Temperature
Warm
Cool
Others:
________________

rigidity

Moisture
__/___
_____

Wounds/drains/dressings:
_____N/A______________________________________________________________________________
Intravenous fluids: PNSS 1L@20gtts/min at Left arm, D5W+NaHCO3 150 meq.(terminate when
consumed with slight discomfort), Dopamine drip 54 cc/hr-discountinued
B. ELIMINATION PATTERN
Usual bowel pattern (Describe character of stool, frequency, discomforts)
Brown Semi-solid stool every other day (1-2 times)
Date of Last BM (mm/dd/yy): _
8/31/2012________________________
Melena _____
Hematochezia _____
Are there any problems with hemorrhoids/incontinence?
Yes __/___
No _____
Use of anything to manage bowels (e.g. laxatives, enema, suppositories, home remedies, antidiarrheals)
__________________________________________________________N/A__________________________________________
______________
Abdomen
General
Configuration
Percussion
Palpation N/A
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:
_____________________
Usual urinary pattern (Describe frequency, character, amount, problem in control, etc.)
____________Urinates for about 3 4 times a day, in a minimal amount, yellowish in
color____________________________________
Dysuria
_____
Hematuria _____
Nocturia _____
Retention _____
Flank pain _____
Polyuria
_____ Oliguria _____
Anuria
_____

C. ACTIVITY EXERCISE PATTERN

Cardiovascular Status N/A
Chest pain/radiation _____
_____
Orthopnea
_____
dyspnea _____

Jugular vein distention _____

Dyspnea

Palpitation

Paroxysmal

_____

Precordial area
Heart Sounds
Flat
_____
Distinct
_____
Bulging
_____
Regular
___/__
Tenderness _____
Faint
_____
Heave
_____
Irregular
_____
Thrill
_____
Others:
Apical rate and rhythm: S3 _____
S4 _____
________86 bpm_____________
Preicardial rub _____
Capillary Refill __2 sec________________________
Presence
of
Pacemaker/A-V
____none_____________________________
Respiratory Status:

Peripheral pulses
Symmetrical
Regular
Faint
_____
Strong
_____
Bounding
_____

Shunt/Hemodynamic

on

exertion
nocturnal

__/___
_____

monitoring

Breathing Pattern

Shape of chest

Regular
__/___ Irregular
_____
Eupnea
_____ Hyperpnea _____
Tachypnea _____
Bradypnea _____
Dyspnea __/___
Rest
_____
Exertion
_____
Use of accessory muscles _____
ICS retractions/bulging
_____
Pain on respiration
_____

Normal APL ratio ___/__

Barrel chest
_____
Funnel
_____
Pigeon
_____

Vocal/Tactile Fremitus
Percussion
Symmetrical __/___
Resonant ___/__
Decreased/increased at:
Dullness at:
____________________
______________
Hyperresonant at:
______________
O2
supplement/ventilatory
assistance
_______
N/A
______________
__________________________
Respiratory Tubes (e.g. ET, trach, chest tube/describe secretions and/or drainage)
_____________________none___________________________________________________

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__0__ Meal Preparation _ 0__
Bed Mobility
__0__
Bathing
__0__
Cleaning
__0__
Chair/Toilet Transfer
__0__
Dressing
__0_
Laundry
__0__
Ambulation
__0__
Grooming __0__ Toileting
__0__
R.O.M.
__0__
Reasons
for
ADL/Mobility
__N/A____________________________________________________________
Device
used
for
___none___________________________________________________________________
Exercise
pattern
(describe
type,
___none____________________________________________________

Limitation
assistance
regularity)

BACK AND EXTREMITIES N/A

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
Midline
_____
Kyphosis

___/__
_____

Gait
_____

Lordosis
Scoliosis _____

Coordinated __/___

Smooth
Staggering _____

_____

Shuffling

Uncoordinated _____

D. COGNITIVE PERCEPTUAL PATTERN

Level of Consciousness
Conscious _/____
Alert
_____ Confused _____
Stuporous _____
Comatose _____
Others ______________

Drowsy _____

Orientation
Emotional State
Oriented __/___
Calm ___/__ Worrried/Anxious _____ Restless
_____
Disoriented to:
Dizziness _____ Numbness
_____
Tingling Sensation _____
Time/Person/Place _____
Others: ________
Head:
Normocephalic __/__
Others: _______

Assymetrical _____

Facial Movements
Symmetrical ___/__
Assymetrical:
lag at R _____L _____

Hair
Fine
Coarse _____
Dry
_____
Alopecia _____

__/___

Enlarged _____ Masses

_____

Scalp
Clean
__/___
Dandruff _____
Lice
_____
Wounds/scars/lesions (specify)
________________________

Eyes:
Lids

Periorbital region

N/A

Conjunctiva

Cornea

and

lens
Symmetrical
___/__
Opacity:
R/L edema/swelling _____
_____ L _____
R/L ptosis
_____
Lesions _______
Lesions
_____
Visual Acuity

Edema

_____

Pink

_____

Sunken

_____

Pale

__/___

Lesions

_____

Discoloration _____

Discharges _____

Peripheral vision

Reaction to accommodation

Grossly normal __/___ Intact/Full

__/___
Uniform constriction/convergence
Farsighted
_____ Decreased/Limited _____
________/ PERRLA__________________
Nearsighted
_____
Unequal constriction/convergence
Wears eyeglasses/convergence
__________________________
___________________
Pupils
Equal ___/__ size __3__ mm
Unequal: R= ___ mm
L= ___ mm
Reaction to light: R: brisk _____
sluggish _____
fixed _____
L: brisk _____
sluggish _____
fixed _____
Ears
External Pinnae
Gross Hearing
Normoset
_____
Normal
___/__
Symmetrical ___/__
Decreased _____

External canal

Tympanic membrane

Discharge:

Intact

(N/A)

Foul smelling _____

___/___

Not intact _____

Tenderness _____
Symmetrical _____
Lesions
_____

Serous

_____

Purulent

______

R/L

deafness

_____
Gross abnormalities:
_________________

Mucoid
______
Cerumen:
Impacted
_____
Not impacted __/___

Nose
Alar flaring _____

Shallow nasolabial fold _____

Septum
Patency
Midline __/___
Deviated _____
Perforated _____

Mucosa

Discharge

Pinkish __/___
Serous _____
Pale _____
Mucoid _____
Reddish ______
Purulent ____

N/A

Both patent __/___

R obstruction _____
L
obstruction

_____
Bloody ______

Masses/lesions(describe):
____________________

Gross smell
Sinuses N/A
Normal/Symmetrical __/___
Tenderness _____
R olfactory deficiency _____
Maxillary _____
L olfactory deficiency _____
Frontal _____
Cognition
Primary language __Visayan___________________________________
Speech
difficulties
________none_________
Are there any learning difficulties?
Yes ______
No ___/__
Are there any change in memory lately?
Yes _____
No ___/__
Pain
No problem _____/_____ Problem __________
Location
__
Type
__
___
Intensity
_
___ _ ___ __
Onset _
___
Duration
_
__
E. SLEEP REST PATTERN
Usual sleep/rest pattern
__5-6 hours of sleep._______________________________
Adequate:
Yes _____
No _____
Factors affecting sleep/rest
___Surroundings
(noise)_________________________________________________
Methods to promote sleep
___none___
______________________________________________________
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: __Patient is weak and
tired.__________________________________________________
G. SEXUALITY REPRODUCTIVE PATTERNS
Are there any changes/problems with sexual relations? __none________________
Female

10

Menstrual pattern
_Normal____________
Date of LMP _May 8,2012_________
Pregnancy history
___G5P4__________________________________________________
Use of birth control measure: Yes __/___
Type:______Pills____________________
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 _____
Lesions _____
Masses at:
____________________
Others
____________________

_____________
Dimpling _____

Edema _____

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?
______Nothing__________________________________________________________________
Support groups/counseling resources used
____none____________________________________________________________

INSTRUCTION: Place an X to the specific area of abnormality during your Physical

Assessment

RR: 28 cpm
Generalized weakness & Pale
Vaginal Bleeding
pale
Folley Bag Catheter
Attached to Urobag

11

wepalepapale

12