Lebanese University

Faculty of Public Health

V
Nursing Sciences
Department
Patient Assessment form

Students Name: _________________

Year/Semester: __________________
Training Field: __________________
Date: __________________________

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

I.

Data Collection:

Patient Name:
Age:
Gender:

Male
Female

Patient Number:
Marital Status:
Single
Widowed

Admission Date:

Admitting diagnosis:

Admitted through:

Height:

Weight:

Denture:
Upper
Lower
Hearing Aids: Right
Left
Eye Glasses:
Yes No
Contact lenses: Yes No
Prosthesis:
__________________
Assisting devices:
____________

Medical History
P F Medical
History
Heart disease
Diabetes
Lung Disease

Allergi Ye N
es
s
o
Food
Drugs
Other

Married
Divorced

Admitting
Physician:

No of children:

Personal Articles: Allergies:

Bed:

Blood Group:

Habits:
Spec
ify

Allergy Band: Yes No

Alcohol: Yes No ___

cup/day
Coffee: Yes No ___
cup/day
Smoke: Yes No ___
pack/day
Exercise: Yes No
Bubbly: Yes No
Others: _________________

Surgical History
P F Medical
History
Hypertension
Blood disorder
Rheumatic
disorder
Liver Disorder
Kidney Disease

Dat Loc Type

e
.

Dyslipidemia
Prostate
Problem
Stroke
Mental Disorder
Cancer
Seizures
Others: ______________________________________
Pre-Admission Medication List

Functional level

Medicati
on

Rout Dos Frequen Last dose

e
e
cy
taken

Activity

Depend
ant

Independ
ant

In Bed
Ambula
te
Daily
act.

Female Reproductive
system
Not applicable
Gravida: ________
________

Para:

Abortion: _______
________

LMP:

Menopausal period:
_______________

Vital Signs Temp:___oC Respiratory:___ /min

BP:____ mmHg

Pulse:___/min

Chief Complaints/ Present illness

(Onset of sickness, duration, symptoms, investigations)

II. Orders:
Date &
Time

Orders

Remarks

II. Orders:

III. Lab Results:

Lab Test

Complete Blood Count

WBC
RBC
Hemoglobin
Hematocrit
Neutrophils
Eosinophils
Lymphocytes
Monocytes
Platelets

Chemistry

Glucose
BUN
Creatinine
Sodium
Potassium
Calcium
Magnesium
Chloride
Carbon
dioxide

Coagulatio
n

PT
PTT
INR

Lipids

Cholesterol
Triglycerides
HDL
LDL

Normal
Range

Pt.
Result
Date:

Pt.
Result
Date:

Pt.
Result
Date:

Remark

Lab Test

Normal
Range

Pt.
result
Date:

Pt.
Result
Date:

Pt.
Result
Date:

Remarks

Urine Analysis

Color
Clarity
Specific
Gravity
pH
Leukocytes
Nitrates
Protein
Glucose
Ketone
RBCs
WBCs
Bacteria

ABGs

pH
PaCO2
PaO2
SaO2
HCO3

Others

IV. Diagnostic Procedures:

Date

Procedure

Result

Analysis

V. Consultation:
Doctor
Consulted

VI. H.G.T.

Specialty

(if applicable):

Date & Time Result

VII. Flow Sheet

Vital
Signs

Date &
Time
Temp
BP
HR
RR
Intake
Outpu
t

Recommendations Remark
s

Insulin
Administered

(if applicable):

Insulin Protocol

In/Ou

Balan
ce
Other
s

VII. Physical Assessment:

Level of
Consciousness

Alert Confused Lethargic Obtunded Stupor

Comatose

Level of Orientation

Oriented
Time

Glasgow Coma
Scale
(for critical patients)

Disoriented
Place

Person

Eye Opening

Verbal Response

Motor Response

4 Spontaneous
3 Verbal
Command
2 Pain
1 No Response

5 Oriented
4 Disoriented
3 Use inappropriate
words
2 Incomprehensive
words
1 No Respone

6 Verbal
Command
5 Localized Pain
4 Flex &
Withdrawal
3 Decorticate
2 Decerebrate
1 No Response

Score: /15(Decorticate = flexes abnormally/ Decerebrate =

flexes normally)

Pupils

Neurological

Sensory

Motor Power

PERRLA or
Equal: Yes No
Lt)
Round: Yes No
Lt)
Reaction: Brisk Sluggish
Lt)
Reactive to light: Yes No
Lt)

( Larger:
( Abnormal:
( No Reaction:

Rt
Rt

Rt

( Accommodation: Rt

Dizziness Numbness Tingling location:

__________________
Vision: Normal Deficit (Rt , Lt) Hearing: Normal
Deficit (Rt , Lt)

Movement
Neck: ____ RUE: ____ LUE: ____ RLE: ____ LLE: ____

Speech

Reflexes

(5 = normal, 4 = 75% normal, 3 = 50% normal, 2 = 25% normal,

1 = paralysis)

Normal
Tremors

Limited Range of Motion Unsteady Gait

Weakness Paralysis

VIII. Physical Assessment:

Chest Expansion

Respiratory Rate: ______ b/min

SpO2: ____%
Symmetric

O2 Therapy: ______

Asymmetric

Breathing Pattern

Breathing Sound

Respiratory

Cough
Sputum

For critical patients

Regular Irregular Shallow Dyspnea ( at rest

on exertion)
Apnea Bradypnea Tachypnea Orthopnea Accessory
muscle use
Clear
Rt
Rt Lt
Diminished Rt
Rt Lt
Rhonchi
Rt
Rt Lt
None
Whitish
Greenish
Thick
Blood tinged
Intubated

Lt

Absent

Lt

Wheezes

Lt

Crackles

Productive

Non-productive

Yellowish
Frothy

Tracheostomy

Brownish
Bloody

BIPAP

CIPAP

Parameters: Mode _________ RR ________ TV ________ FiO2 PEEP

______

Heart Rhythm
Heart Sounds
Capillary refill
Peripheral Pulses/
Edema

Cardiovascular

Intravenous Access

Blood: ________ mmHg

_______ b/min

Heart Rate:

Regular

Irregular

S1 S2
Etc)

other: (S3, S4, Murmur, Valvular Click,

Normal (3)

Delayed: _____ sec

Peripheral
Pulses
Strengt
h*

Edema

Brachia
l

Hands

Radial

Femor
al
Poplite
al
Tibial

Abdom
en
Knees

Legs

Ankle

D.
Pedis

Scrotu
m

N
o

Ye
s
R/
L
R/
L
R/
L
R/
L
R/
L
R/
L

NonPitting

Pittin
g

Grad
e*

Strength*: Absent (0), Thready (+1), Weak (+2), Normal (+3),

Bounding (+4)
Grade*: Quickly disappears(1), disappears in 10-15sec (2), 1-2
min (3), >2 min (4)

Peripheral
______________

Central

VIII. Physical Assessment:

Polysite

Site:

Diet: _______________
Inadequate

Oral Mucosa
Tongue

Gastro-Intestinal

Abdomen

Nutritional Intake: Adequate

Intact
Pale

Moist

Dry

Intact
Patches

Cracked

Swollen

Nausea: Yes No

Pink

White

Vomiting: Yes No

Bowel Sounds
Soft
Ascites

Bowel Pattern
Tube/Stoma

Tender

Distended

Active in all quadrants

Absent
Hyperactive
__________

Hypoactive

Hard

Location:

Normal
Diarrhea
Constipation
Incontinence
Last Bowel Movement: _____________
Stool Color:
_____________
None N/G tube
Others: ______

Gastrostomy

Colostomy

Assessment of
Urethra

Normal
Urethral Abnormalities
Urethral Discharge

Assessment of
Vagina

Normal

Genitourinary

Assessment of
Urination

Voiding
Urine Output
Urine Color

Vaginal Discharge

Normal
Burning
Bladder Distension

Frequency
Urgency
Pelvic Pain
Flank Pain

Freely
Foley Catheter
Continent Incontinence
__________
Normal

Polyuria

Yellow

Orange

Urostomy
Dialysis

Oliguria
Pink

CBI
Others:

Anuria
Red

tinged

Urine Characteristics

Grossly Bloody
Amber

Amber

Clear
Odor

Sediment

Cloudy

VIII. Physical Assessment:

Dark

Abnormal

Pain

Pain

Tool Used
Provoke
Quality

Region/Radiation
Severity
Time

No Pain

VDS/VAS
CPOT

Faces

Behavioral

What initiates the pain: _____________

__________
Are you on pain management: ______
___________

What aggravates it:

What relieves it:

Character: ______________
(Sharp, dull, stabbing, burning, throbbing, twisting, stretching,
etc)

Location: __________________
________________

Radiate to:

Scale: _______/10
Duration: __________________
________________

Skin Color

Integumentary

Skin Temperature

Skin Is

Normal
Warm

Pale
Hot

Jaundice
Cool

Frequency:

Cyanosis

Cold

Intact
or with
Ecchymosis
Hematoma
Lesion/ Laceration

Palpable mass
Pressure Ulcer: Location: _________
Stage: ________
Color: ______
Length: ____ Width: _____ Depth: _____
Slough/Eschar
Pressure Ulcer management: _____________________________

Surgical Wound

Wound Assessment

Discharge

Normal
Redness Swelling Tenderness Dehiscence
None
Bloody Purulent Serous Serous-sanguineous
Biliary Odorous

Amount

Minimal Moderate Excessive

Drainage

None Yes
Penrose Jackson-Pratt Hemovac Vacuum Drainage

Nursing Note

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

IX. Medications:
Drug (Brand
Name)

Generic Name

Classification

Route & Dosage

Ordered
(PRN/Stat/Stand
ing)
Mode of Action

Indications

Contraindication

1.

2.

3.

4.

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Nursing
Considerations

IX. Medications:
Drug (Brand
Name)

Generic Name

Classification

Route & Dosage

Ordered
(PRN/Stat/Stand
ing)
Mode of Action

Indications

Contraindication

5.

6.

7.

8.

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Nursing
Considerations

X. Nursing Diagnosis:
Nursing
Diagnosis

Nursing
Diagnosis
Related to

Expected
Outcome

Nursing Interventions

Evaluation
s

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

X. Nursing Diagnosis:
Nursing
Diagnosis

Nursing
Diagnosis

Expected
Outcome

Nursing Interventions

Evaluation
s

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

Related to

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

XI. Daily Plan:

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

XII. Disease or Condition Research:

1. Name of Disease/definition/pathophysiology:

2. Signs and symptoms are:

3. Medical or surgical care & treatment:

4. Diagnostic tests for this disease (include lab & X-Rays, etc.):

Lebanese University
Faculty of Public Health V
Nursing Sciences Department

5. Nursing Care for this disease (include examples of diet):

6.

Teaching with discharge planning (include S/S to report to doctor):