MINDANAO STATE UNIVERSITY

Iligan Institute of Technology

DEPARTMENT OF HEALTH SCIENCES

NURSING HEALTH ASSESSMENT

General Information

Vital Signs
When did you have your blood pressure checked last? ______________________________________
Do you know the reading? ____________________________________________________________
Heart Rate _____________ Height __________ (cm/feet, inches) (actual/stated)
Respirations____________ Weight__________ kg/lbs.) (actual/stated)
Do you have a thermometer? ____________ Do you have a scale? __________________________________________
Have you been in a hospital / health facility in the past 15 days? [ ] No [ ] Yes
Name of facility/Nature of the Problem: ________________________________________________________________

Allergies / Sensitivities (medicine, food, dust, etc)

Source
________________________________________
________________________________________
________________________________________
________________________________________
Reaction
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Functional Health Patterns

Health Perception/Health Management Pattern
1. Do you have any health issues that you would like to improve? _________________________________
______________________________________________________________________________________
2. Preexisting conditions, surgeries, procedures: ______________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
3. Have you been exposed to any communicable diseases within the past year?
[ ] No [ ] Yes _________________
4. Medications taken at home (include prescription, over the counter, herbal remedies, vitamins)
Name Dose/Frequency/Route Reason for taking
1. _______________ _______________________________ ________________________________________
2. _______________ _______________________________ ________________________________________
3. _______________ _______________________________ ________________________________________
4. _______________ _______________________________ ________________________________________
5. _______________ _______________________________ ________________________________________
6. _______________ _______________________________ ________________________________________
7. _______________ _______________________________ ________________________________________
8. _______________ _______________________________ ________________________________________
5. Do you experience any problems from your medications?
[ ] No [ ] Yes What do you do about it?________________________ Nursing Diagnosis
6. Do you experience any problems buying your medications/supplies? Noncompliance
[ ] No [ ] Yes If yes, explain: ________________________________ Risk for Injury
Health-Seeking Behaviors
7. Have you ever had a blood transfusion? Ineffective Health Maintenance
[ ] No [ ] Yes Reaction? (type) ____________________ Ineffective Protection
8. Did you have the following screenings done in the past year? Risk for Infection
[ ] Breast self exam [ ] Prostate check [ ] Vision check Effective Management of Therapeutic
[ ] Mammogram date: _____ [ ] Testicular check [ ] Glaucoma Regimen
[ ] Pelvic exam/Pap smear [ ] Rectal check [ ] Dental exam Ineffective Management of Therapeutic
Regimen

Nutritional – Metabolic Pattern Fluid Volume Deficit

1. Do you follow a special diet? Fluid Volume Excess
[ ] No [ ] Yes, ________________________________ Impaired Swallowing
2. When was the last time you ate? ____________________________________ Impaired Dentition
Nausea
3. Have you been asked to increase/restrict your fluid intake? High Risk for Aspiration
[ ] No [ ] Yes _________ Amount __________________ /day Imbalanced Nutrition: Less
4. Dentures? [ ] Upper [ ] Lower [ ] Partial Than Body Requirements
5. Appetite [ ] Normal [ ] Increased [ ] Decreased Imbalanced Nutrition: More
6. Do you have difficulty with? than Body Requirements
[ ] No [ ] Choking [ ] Smell [ ] Chewing Impaired Oral Mucus Membrane
[ ] Swallowing [ ] Tasting [ ] Following diet
Related to: ________________________________________________ High Risk for Imbalanced Body
7. Do you have? [ ] No [ ] Nausea [ ] Vomiting Temperature
[ ] Indigestion [ ] Weight loss/gain ______ kg/lbs. Hypothermia
[ ] Mouth [ ] Persistent fever Hyperthermia
Impaired Skin Integrity
Soreness
Impaired Tissue Integrity
Adult Failure to Thrive
8. Skin/Mucosa ________________________
Color: [ ] Pink [ ] Flushed [ ] Cyanotic [ ] Ashen
[ ] Pale [ ] Mottled [ ] Jaundiced
 Temperature/Moisture: [ ] Warm [ ] Cool
[ ] Hot/dry [ ] Cold/clammy
Turgor: [ ] Normal [ ] ____________________________________
Edema: [ ] None [ ] Generalized [ ] Localized:____________________
(describe location and degree 1-4+)
8. Wounds/Drains/Tubes/Catheters/Dressings: [ ] None _______________________
_________________________________________________________________________
9. Oral Mucous Membranes: [ ] Not Applicable
[ ] Intact [ ] Lesions ______________________________________________
[ ] Moist [ ] Dry
Color: [ ] Pink [ ] Pale [ ] Cyanotic [ ] Other________________________
10. Braden Skin Risk Assessment Score
15-16 Low risk 13-14 Moderate risk 12 or less Severe risk

Elimination Pattern
1. Are you having any problems with bowel/bladder elimination? Constipation
Diarrhea
[ ] No [ ] Yes, describe: __________________________________ Bowel Incontinence
2. Abdomen Altered Patterns of Urinary
[ ] Soft [ ] Firm Elimination
[ ] Nontender [ ] Tender: Location ____________________________ Urinary Retention
[ ] Nondistended Total Incontinence
[ ] Distended: Girth _____________________________
Stress Incontinence
[ ] Ostomies/tubes: type _______________________________________Functional Incontinence
Care (circle): independent, needs assistance Urge Incontinence
Bowel Sounds ________________________
[ ] Present [ ] Absent [ ] Other _______________________
3. Bladder
[ ] Nondistended [ ] Distended
Comments: _______________________________________________________
_________________________________________________________________

Activity – Exercise Pattern

1. Do you have enough energy for desired/required activities? [ ] Yes [ ] No Fatigue
Activity Intolerance
2. Do you need assistance with? [ ] Not applicable Self-Care Deficit
[ ] Eating/Drinking [ ] Walking [ ] Sitting (specify) ________________
[ ] Toileting [ ] Getting up from bed/chair[ ] Preparing meals Impaired Home Maintenance
[ ] Bathing [ ] Stair climbing [ ] Shopping Impaired Physical Mobility
[ ] Dressing [ ] Turning High Risk for Disuse
Comments: _____________________________________________________ syndrome
High Risk for Injury
3. Mobility Impairments [ ] None [ ] Unable to assess Risk for Falls
[ ] History of falling [ ] Tremors/Spasms____________________ Impaired Physical Mobility
[ ] Dizziness [ ] Paralysis ___________________________ ________________________
[ ] Unsteadiness/Balance ________________________
[ ] Decreased Function __________________
[ ] Amputation_________ [ ] Numbness, Tingling, Burning _____________________
[ ] Impaired limb _______
Risk Fall Assessment [ ] No Risk [ ] Low Risk [ ] High Risk

Gross Motor Movements:

Normal Abnormal Comments______________________________________
Gait [ ] [ ] _______________________________________________
Posture [ ] [ ] _______________________________________________
ROM [ ] [ ] _______________________________________________
4. Do you use any assistive devices at home? [ ] No [ ] Yes
5. Muscle Strength (see Key) Muscle strength key
[ ] Not applicable +5 = able to move against full resistance
left arm _____ +4 = able to move against gravity and mod resistance
right arm _____ +3 = able to move against gravity but no resistance
left leg _____ +2 = weak movement, unable to overcome gravity
right leg _____ +1 = flicker of muscle movement
0 = no movement
6. Respiratory Assessment
Respiratory effort [ ] Easy [ ] Use of accessory muscles
Respiratory pattern [ ] Regular [ ] Irregular: ____________________
Breath sounds Right Left Ineffective Airway Clearance
Clear [ ] [ ] Impaired Gas Exchange
Diminished [ ] [ ] Ineffective Breathing Patterns
Coarse/Rhonchi [ ] [ ] Cardiac Output, Decreased
Crackles/Rales [ ] [ ] Ineffective __________________
Tissue Perfusion
Wheezing [ ] [ ] ________________________
Absent [ ] [ ]
Cough [ ] No [ ] Yes Sputum [ ] No [ ] Yes:_________________

7. Cardiovascular Assessment
Rhythm_____________________
Heart Sounds________________
Neck Veins [ ] Flat [ ] Distended
 Peripheral pulses (0 = absent, +1 = weak, +2 = normal, +3 = bounding
Dorsalis Pedis Posterior tibial Radial Other
Right _____________ ____________ ________ _______
Left _____________ ____________ ________ _______

Sleep – Rest Pattern

Sleep Pattern Disturbance
[ ] Not applicable Sleep Deprivation
[ ] Deferred
1. Have you had difficulty sleeping prior to admission?
[ ] No [ ] Yes, describe:____________________________________
2. Difficulty falling asleep? [ ] No [ ] Yes
3. Early awakening? [ ] No [ ] Yes
4. Abnormal cycle of sleeping
daytime sleeping [ ] No [ ] Yes
awake at night [ ] No [ ] Yes

Cognitive – Perceptual Pattern

1. Orientation Level of Consciousness Confusion, Acute
[ ] Not oriented [ ] conscious Confusion, Chronic
Disturbed Thought Processes
[ ] Oriented to Person [ ] lethargic, sleepy, drowsy Impaired Verbal
[ ] Oriented to person, place [ ] stupor – aroused by verbal stimuli Communication
[ ] Oriented to person, place, time but responds poorly to pain Impaired Memory
[ ] light coma – no response to verbal stimuli Sensory-Perceptual
but responds to pain Disturbed (specify)_________
[ ] deep coma – no response to painful stimuli High Risk for injury
Pain Acute
2. Pupils [ ] Not applicable Describe:___________________________ Chronic Pain
3. Clarity of speech [ ] Clear [ ] Slurred [ ] Aphasic Knowledge Deficit
Primary language if not English:______________________________ (specify)_________________
4. Thought Process [ ] Logical [ ] Illogical (confused) [ ] flight of ideas ________________________
5. Deferred [ ]
What is the highest grade in school you have completed? _______
Occupation:___________________________________________
Do you have problems with your memory? [ ] No [ ] Yes ________________
Hearing Aid [ ] No [ ] Right ear [ ] Left ear
Glasses/contacts [ ] No [ ] Yes
Do you have any problem with your ability to feel pain, temperature? [ ] No [ ] Yes
Describe:_______________________________________________________
Have you ever had a seizure? [ ] No [ ] Yes How often?__________________
Describe your seizure __________________________________________________
When was your last seizure?_____________________________________________
Do you have pain? [ ] No [ ] Yes
If yes, (type, duration, location) Describe: __________________________________________________
How do you get relief from your pain? _____________________________________________________
What do you need to learn to be able to care for yourself after discharge?____________________________
______________________________________________________________________________________

Self – Perception Pattern Self-concept Disturbance

Behaviors indicate the following Body Image Disturbance
1. Mood [ ] Calm [ ] Agitated [ ] Angry Anxiety
[ ] Anxious [ ] Sad [ ] Other _______________ Fear
2. Affect [ ] Normal [ ] Labile [ ] Flat Hopelessness
Powerlessness
3. Verbal Style [ ] Interactive [ ] Quiet [ ] Talkative [ ] Guarded
4. What outcome do you expect from this hospitalization?___________________
________________________________________________________________

Role – Relationship Pattern Interrupted Family Processes

1. Lives [ ] Alone [ ] With ___________________________________ Chronic Sorrow
2. Who will assist you with your care after discharge? [ ] No one Ineffective Role Performance
Impaired Social Interaction
______________________________________________________________ Social Isolation
3. Resides: [ ] House [ ] Apartment [ ] Assisted [ ] Living Caregiver Role Strain
[ ] 24 hour nursing care provided Grieving, Anticipatory
4. Environmental/Safety concerns (stairs, inaccessible bathrooms, etc) [ ] NoneGrieving, Anticipatory
Describe: _____________________________________________________
5. Any current family difficulties of concern to you? [ ] None
Describe: _________________________________________________________

Sexuality – Reproductive Pattern

Sexual Dysfunction
1. Do you have any questions/concerns about the effects your physical condition Ineffective Sexuality Patterns
or medications may have on your sexual activity? ________________________
[ ] No [ ] Yes ________________
2. Females [ ] post menopausal
date of last menstrual period?_____________________________
Coping – Stress Pattern
1. Have you had any recent major life-style changes? Impaired Adjustment
[ ] No [ ] Yes, describe __________________________________ Ineffective Individual Coping
Suicide, Risk for
2. How do you deal with stressful situations? __________________________ Post-Trauma Syndrome
______________________________________________________________ ________________________
______________________________________________________________
_________________________________________________________________

Value – Belief Pattern

1. Religious preference:___________________________________________ Spiritual Distress
2. Are there any religious or cultural practices that may be affected by this ________________________
hospitalization? [ ] No [ ] Yes, describe____________________
3. Would you like to see a Chaplain? [ ] No [ ] Yes
4. Advance Directives reviewed for completion [ ] No [ ] Yes
Has patient discussed advanced directives with physician? [ ] No [ ] Yes
5. Further actions if applicable
[ ] patient given additional information
[ ] patient referred to [ ] social work [ ] pastoral services other_______