BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING

ASSESSMENT TOOLS

I. DATA BASE AND HISTORY

Name of Patient: Date of Birth: Sex: Age:
Address:
Religion: 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:

Has received blood in the past? Yes No if yes, list dates

Blood reactions if any:

Allergies:
Food:
Medications:

Admitting Diagnosis:

Attending Physician:
Consultant:

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 I. NURSING ASSESSMENT
A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, comfort.
Objective Subjective
General Appearance: □ Alert/responsive Usual Diet:
□ Apathetic □ Cachexia □ Abdominal Distention No. of meals per day: ___________ (3x a day)
No. of fluid drink each day: (8-12 glasses/day)
□ Mass □ Tenderness/pain

Skin: □ Dry □ Warm □ Cold □ Moist □ Alcohol and Beverages

□Edema Undesired Weight loss: □ Yes □ No
Turgor: Undesired Weight gain: □ Yes □ No

Food restrictions R/T intolerance and health

Eyeball: □ Sunken □ Moist □Dry
problems or religious practices?
Mouth: □ Dentures □ Braces □ Lesions
□ Cleft Palate □ Cleft Lip □ Ulcers
No. of teeth:
Difficulty in eating and swallowing:
Tongue: □ Dry □ Moist □ Furrows

Venous filling: (Normal less than 3-5 sec)

Intravenous Fluid: Previous/Recent Illness:

Date of insertion: □ Diabetic □ Hyperthyroidism □ Hypothyroidism
□ Colon Cancer □ Abdominal Pain
Wounds: Comment:
Tube/Drainage:

Vital Signs: T P R BP Elimination pattern: □ Diarrhea □ Constipation

Frequency of BM: /day
Body Types:
□ Ectomorph □ Mesomorph □ Endomorph
□ Obese □ Thin

Loss of Appetite: □ Anorexia □ Bulimia

Body weight: kg

Remarks:

Nursing Diagnosis:

B. RESPIRATORY SYSTEM
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 Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective Subjective
Breath Sounds: □ Diminished/Absent □ Stridor Previous/Recent Illnesses:
□ Rales/Crackles □ Rhonchi/Wheezing □ Bronchitis □ Emphysema □ Asthma
□ Normal (Vesicular, Bronchovesicular, Bronchial) □ Brochiectasis □ Pneumonia
□ None (atelectasis) □ Hydrothorax
□ Pneumothorax □ Hemothorax □ CHF
Resonance: □ Hyper □ Hypo □ Chest Trauma □ Lung Cancer
Comment:
Respiration/Oxygenation:
□ Normal(Relax, Effortless and Quiet)
□ Labored/Use accessory Muscle] □ Dyspnea
□ Tachypnea □ Bradypnea □ Cyanosis Breathing Treatments/Medication:
□ Pallor □ Cheyne-stoke □ Biot’s
□ Hyperventilation □ Hypoventilation
□ Nasal Flaring □ Pursed lip □ Barrel Chest
□ Pleuritic Pain Smoking:
□ O2 Inhalation liters/min □ Yes For how long:
Rate:
□ No
Comment:
Tube/Drainage: □ CTT □ Oral Airway
□ Endotracheal Tube □ Ventilator

Cough: □ Productive □ Non-productive

Sputum: □ Mucoid □ Bloody (hemoptysis)
□ Rusty □ Frothy □ Thick Tenacious
Color: ____________________________

Remarks:

Nursing Diagnosis:

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 C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective Subjective
Temperature: Celsius Previous/Recent Illness:
Blood Pressure: Right Left □ CVA □ CHF □ MI □ Thrombophlebitis
□ Family History of HPN □ Renal Failure
Pulses:
Carotid Pulse: □ Thready □ Weak □ Strong □ Absent
□ Bleeding Disorder
Rate: Right______Left______ Comment:

Apical: □ Regular □ Irregular Rate: ____

Radial Pulse: □ Regular □ Irregular □ Thready □ Weak □

Strong □ Absent Rate: Right______ Left _______

Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak Do you experience any of the following:
□ Strong □ Absent Rate: Right_____ Left _____ □ Chest pain □ Arm pain □ Leg pain
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak □
□ Joint and Back □ Dyspnea □ Orthopnea
Strong □ Absent Rate: Right_____ Left _____ □ Cough □ Numbness and Tingling
□ Light headedness □ Fatigue and weakness
Heart Rhythm: □ Tachycardia □ Bradycardia □ Palpitations
□ Arrhythmia/ Dysrhythmia Comment:

Jugular Veins Distention:

□ Positive □ Negative
Exercises:
Type:
Nail bed Color : □ Pink □ Blue □ Pale Frequency:
Duration:
Capillary Refill: (Normal less than 2 sec)
Problem experience with usual activity and exercise:
Edema: □ Pitting □ Non Pitting Comment:
Location: _____________________________

Varicosities: □ Yes □ No Factors Affecting Activity Intolerance:

Location: Comment:

Calf Tenderness (Homan’s Sign):

Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks:

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 □ moist Comment:
Turgor:
□ Pallor □ Cyanosis □ Jaundice □ Rashes
□ Acanthosis Nigricans □ Albinism □ Erythema
□ Edema □ Petechia □ Itching □ Drainage
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer Comment:
Temperature:

Hair: □ Alopecia □ Hirsutism □ Patchy hair loss Comment:

Distribution:

Nails: □ Dirty □ Pallor □ Cyanosis

□ Clubbing □ Paronychia □ Onycholysis
Capillary refill: (Normal less than 2 sec)
Color:
Remarks:

Nursing Diagnosis:

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 E. ELIMINATION
Objective Subjective
Mobility and Dexterity: Previous/Recent Surgery/Illness:
□ Ambulatory □ Non-ambulatory
□ Bedridden □ with assistive device
History of pain and discomfort:
Tubes/Drainage/Stoma:
□ Colostomy □ Ileostomy □ NGT Diet:
□ Catheter □ Suprapubic Catheter
Personal Elimination Habits:
Abdomen: □ Soft □ Firm
□ Distended □ Non-distended
Elimination Problem:
Bowel Sounds: (5 – 20 sounds/min) □ Loose bowel movement _________
□ Normoactive □ Hypoactive □ Constipation □ Impaction □ Fecal Incontinence
□ Hyperactive(Borborygmi) □ Absent □ Neurologic Impairment □ Dysuria □ Urgency
□ Polyuria □ Oliguria □ Nocturia □ Dribbling
Measurement: □ Incontinence □ Hematuria □ Retention
Intake Output: □ Discharge
□ Residual urine (> 100ml)
Edema: □ Yes □ No Comment:
Location:

Present Urine Color:

Medication taken: □ Analgesic Narcotic
Note: Assess urine frequency, color, odor control, □ Antibiotics □ Anticholinergic □ NSAID
comfort/gyn-bleeding, discharge. □ Aspirin □ H2 antagonist

Comment: Fluid intake per day: liters/day

Physical Activity:
Comment:

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, comfort.
Objective Subjective
Mobility: □ Ambulatory □ Non Ambulatory Do you experience any of the following:
□ Bedridden □ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Appliance __________________________ □ Joint pain
Comment
Gait and Posture: □ Lordosis □ Kyphosis
□ Scoliosis □ Shaftling □ Poliomyelitis
□ Amputated Limb ______________________
Comment:
Club foot (Talipes)
□ Varus □ Valgus □ Equinovarus □ Calcanous
□ Use of Appliance __________________________
Comment:
Muscle Tone/Strength:
□ Normal □ Slight weakness
□ Average weakness □ Poor ROM
□ Severe Weakness □ Paralysis
□ Atrophy □ Hyperatrophy
□ Spasm
Comment:
Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
□ Contractures/Deformities □ Crepitus
□ Tingling/Numbness (Carpal Tunnel Syndrome)
□ Ankylosis □ Foot Drop □ Pressure Ulcers
□ Urinary Elimination changes _________________

Calf Tenderness (Homan’s Sign):

Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks:

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 Check the following Risk Factors:
□ Unresponsive □ Obtunded □ Stupor □ Older Adulthood □ Male□ Hx Stroke or TIA
□ Hypertension □ Smoking □ HX CVD
□ Decorticate □ Decerebrate
□ Drug Abused □ DM □ Oral
□ Sleep Apnea □Contraceptives
GCS Score:
□ Menopausal □ Over Weight
□ High level of Cholesterol
Crushing Triad (Respiratory changes, Increase BP, Comment:
Decreasing level of Consiousness)
□ Positive □ Negative

Sensation: □ Positive □ Negative Do you experience any of the following:

□ Blurring □ Diplopia □ Photophobia
Pupillary Size: □ PERRLA □ Anisocric □ Pain □ Inflammation □ Cataract
□ Glaucoma □ Headache □ Unusual Discharges
Orientation: □ Person □ Place □Time/Date Comment:
□ Pain

Sensory Function: □ Positive □ Negative

Location:

Motor Funciton: □ Positive □ Negative

Location:

Vital Signs: BP: T: P: R:

Brudzinski’s Sign: □ Positive □ Negative
Kernig’s Sign: □ Positive □ Negative

Reflexes:
Patellar □ Positive □ Negative
Biceps □ Positive □ Negative
Triceps □ Positive □
Negative
Achilles □ Positive □ Negative

Remarks:

Nursing Diagnosis:

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 III. LABORATORY AND DIAGNOSTIC EXAMINATION
LABORATORY AND
Date Ordered Result Significance
DIAGNOSITC