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SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Adolescent-Adult Assessment Tool
(13 y/o and above)

Preliminary Information:
Patients Initial:________________________ Age: ___ Sex Male Female Civil Status _______ Occupation______________
Informant: ___________________________ Relationship of Informant to patient: _______________ Religion ____________________
Date of examination: ___________________ Area of assignment____________________ Day of hospitalization __________________
Allergies: Food: _____________________ Drugs: ___________________ others: ________________________________
VS : T_______ BP____ / _____P______ RR_______ O2 Sat______ Weight: _________ Height ___________
PAIN and DISCOMFORT Diagnosis:__________________________________________ CARE CONCERNS
Presence of Pain/discomfort: None Yes Pain
Intensity score: ___Location:___________ Radiation:____________ Duration: _______ Onset :_________ Altered Comfort
Quality: cramping dull burning sharp shooting throbbing others:_______________ Activity Intolerance
Aggravated by: movement light pressure others:____________________________________ Ineffective Coping
Relieved by: eating quiet environment cold heat rest others_______________________ Others:________
Medication/s: _____________________ Non-pharmacologic mngmt: __________________________
Objective data: grimacing guarding affected area crying withdrawal others:_________________
Effect of pain to sleep_______ emotions _________ appetite___________ activity ______________
Effects of pain: nausea/vomiting Others _________________________________________________
HEENT Diagnosis:_________________________________________________________ CARE CONCERNS
HEAD: asymmetrical unable to support head midline & erect facial color: _______ pain/discomfort Sensory/Perceptual
HAIR/SCALP: alopecia baldness infestations abnormality:________________________ Alteration
EYES: nystagmus strabismus Lens Opaque Clear __ L __R Color of sclera:______ edema Body image
acuity problems:___________ uses corrective lens:__________ others:______________________ disturbance
EARS: discharges:_____ pain:_____ swelling:_______ tinnitus hearing problems: __L __R Impaired Swallowing
NOSE: nasal discharge epistaxis occlusion sinus tenderness:_______ others ________________ Risk For Injury
MOUTH: Lips: intact cracked lip color______ others:____________________________ Risk For Aspiration
Mucus membrane: moist dry sores lesions _________ bleeding others_____________ Others:________
Dental: decays ________ uses dentures chewing problem gingivitis others______________
Tonsils: pain swelling : size ______ swallowing difficulties others____________________
NECK:/THROAT: hoarseness speech difficulty lump lymph node tenderness:____________
thyroid enlargement: grade:_____ torticollis lymph node enlargement___________________
attached appliances/ devices(IJC,Trach) status:___________________________________________
Others ________________________________________________________________________________
Medication/s ___________________________________________________________________________
Dx result ______________________________________________________________________________
NEURO Diagnosis:_________________________________________________________ CARE CONCERNS
LOC: oriented disoriented unresponsive Seizures
GCS score: M___ V___ E___ Total=___ Sensory state Delirium
Speech: normal dysphasia slurred blocking poverty of speech Aspiration
selective mutism aphasia ( Expressive Receptive Global) Language
Cognition: Orientation: time place person self Depression
Memory: immediate recent remote Decreased ADLs
Pupils: size: ______ reaction: _______________ deviation: ____________________ Sensory
Cranial nerves: abn findings______________________________________________ thought process
Swallowing: normal dysphagia others ___________________________ Others:_________
Behaviors: calm restless agitated withdrawn others:________________ __tactile
Seizures: No Yes Type: ____________ Duration: ____ Incontinence ______ discrimination
SCI:level of injury:___ complete incomplete sensory: light touch __ pin prick___ __2 pt
anal sensation ___ bladder sensation ___ Motor: diapraghm ___ abdominal ___ discrimination
anal control__ bladder control ___ Elbow: flexors___ extensors ___ __stereognosis
fingers: flexors __ abductors__ ; hip flexors ___ ; knee extensors ___ ; __graphesthesia
ankle: dorsiflexors ___ plantarflexors __ ; long toe extensors ___
Others: +brudzinski +kernigs headache:________ vertigo syncope
Others ________________________________________________________________

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Medication/s ___________________________________________________________
Dx result _____________________________________________________________
MUSCULO-SKELETAL Diagnosis:______________________________________________ CARE CONCERNS
Falls
Mobility: hemiplegia ____ quadriplegia paraplegia ____ paresis _______ Motor strength
Decreased ADLs
Muscles: spastic flaccid tremors tics spasms pain_____________ &DTR
Sensory deficit
Muscle mass: adequate emaciated atrophy _________ others ____________
Disuse Syndrome:
Assistance Needed: none partial full assistive device: _________________
Sp:________________
Joints: ROM: full limited:_________ redness :_________ edema:_________
Impaired Physical
stiffness:________ arthritis tophi:________ deformities _______________
Mobility
Amputations:_________________ contractures:_____________ foot drop
Impaired Bed
Coordination: impaired __________ slowed Gait: _______________________
Mobility
Posturing: kyphosis lordosis scoliosis decorticate decerebrate
Others:_________
opisthotonus others:__________________________________________ Hand Grip:
Functional disability: feeding toileting transfer dressing others___________ L: ______
Supports: cast:_________ sling:________ traction:____________________ R:______
Others __________________________________________________________________ Foot pushes:
Medication/s ______________________________________________________________ L:_______
Dx result _________________________________________________________________ R:_______
RESPIRATORY Diagnosis:_______________________________________________________ CARE CONCERNS
Anterior: Posterior: Airway Clearance
Chest shape: ____________ deformities _____________ pain/discomfort
Gas exchange
Rhythm : regular irregular (sp)________________________________
Actual/potential
Depth : normal shallow deep mouthbreathing
Infection
Quality : normal labored stridor egophony
Tissue
Expansion: symmetrical asymmetrical paradoxical
Perfusion
flaring retractions: _________ accessory muscles: ___________
Lung sounds:
Dyspnea: absent at Rest with Activity SOB orthopnea
A-Absent Others:__________
Cyanosis : absent central peripheral
C-Clear (Normal)
Cough : absent dry harsh productive non-productive hemoptysis
D- Decreased
Secretions color/amt: ______________ night sweats
W- Wheeze
Fremitus: present absent
Cf - Crackles (fine)
Chest Tubes(loc/charac/status):_____________________________________
Cc Crackles (coarse)
Oxygen therapy: via________ LPM _______
Lung percussion:
MechVentilator : type:_______ setting: ____________ mode: ______
R-resonant
Artificial airway: ET NT TT others_________________________
H-hyper resonant
Medication/s _____________________________________________________
F-flat
DX Result: ______________________________________________________
Dl -dull

CARDIOVASCULAR Diagnosis:___________________________________________________ CARE CONCERNS


Activity intolerance
chest pain palpitations nails: color_________ clubbing capillary refill:_____ seconds
Impaired comfort
Apical pulse: rate: ____ regular irregular Pulse Deficit: No Yes PMI:______
Cardiac
Abnormalities: murmurs:______ thrills:______ bruit:________ heaves: _______
Output
dynamic precordium pericardial friction others _____________ JVD:Meas._________
Tissue
Auscultatory areas: Aortic:____ Pulmonic: _____ Tricuspid: ______ Mitral:______ S1 S2
Perfusion
Cardiac Monitor: yes no Pace maker: no yes Rhythm : regular irregular:____________
Skin Integrity
Pulses : Radial ____L____R Femoral ____L____R Pedal ____L____R
Others: ________
Edema: pedal L/R ankle L/R lower leg L/R face non-pitting pitting Grade: _________
Type of IV line: central loc. ________ peripheral loc. _________ IV infiltration char:____________
CVP leakage CVP level:____ varicosities __________ fistula/shunts: loc _____________
Hema: bruising:___petechiae ___ ecchymosis ___purpura ___ hematoma
BT Type of BT: ________________ :#of units_______ reactions:_____________________
CBG: _____ q ______ insulin type: ____________ units: ___________
Others:_______________________________________________________________________________
Medication/s :___________________________________________________________________________
Dx results: _____________________________________________________________________________

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GIT and GUT Diagnosis:____________________________________________________ CARE CONCERNS
Nutrition
Diet: oral type: ____________________preference: ______________ NPO (SINCE):________
Aspiration
Breakfast ( 100% 75% 50% 25% 0%) others: ____________________________
Swallowing
Lunch: ( 100% 75% 50% 25% 0%) others: _____________________________
Fluid
Dinner: ( 100% 75% 50% 25% 0%) others: ____________________________
Constipation
BMI: _________ TPN: PPN type: ______________ rate: ___________ tolerated: ( yes no)
Diarrhea
Enteral tube type: NGT gastrostomy jejunostomy others: _______________________
Bowel Elimination
Insertion date: _________ NG tube suction: low gravity
urinary elimination
heartburn anorexia nausea emesis (describe): _______________________________
gastrointestinal
Bowel Sounds: normoactive hypoactive hyperactive absent
motility
Abdomen: soft tender firm distended rigid tympanic
Skin Integrity
dull ascites fluid waves bruit @________
Others___________
Abdl girth: ____ waist C: ___ hip C: ___ w/h ratio______ BMI:_________
Bowel Activity: normal regularity : __________ Last BM:___________
Feces: color________ amount/size:___________ characteristics:_________________________________
diarrhea constipated (# of Days) _____ Aids to BM:___________________________________
melena hemorrhoids others_____________________________________________________
Liver: tenderness enlargement esophageal varices others:____________________________
Kidneys: flank pain BUN_______________Crea: _________________
Voiding: continent incontinent frequency urgency hesitancy burning nocturia
dysuria anuria hematuria others:_________________________________________
Urine: characteristics: _______________________output: (7 3): _____311: _____11 7: _____________
Mass: (Location): _______________ characteristics: _________________________________________
Dialysis: hemodialysis:__________ peritoneal:________ Fluid restriction: ______ml/day
Catheter: Foley Suprapubic Condom Peritoneal A/V Fistula
Bowel Diversion: (charact/site): __________________________________________________________
Urinary diversion: (charact/site): _________________________________________________________
CBI: type of solution _____________________ drainage: __________________________________
Medications:__________________________________________________________________________
Screening Methods: colonoscopy sigmoidoscopy barium Enema barium sw. FOBT
Last Date Performed: ________ Results: ___________________________________________________
Lab results: S/E:______________ UA: _______________ AST/ALT________ Albumin_________
Other Dx result:________________________________________________________________________
Surgeries: ___________________________________________________________________________
Medications:__________________________________________________________________________
REPRODUCTIVE SYSTEM Diagnosis________________________________________________ CARE CONCERNS
FEMALE Breast (draw abnormalities here) Sexual Patterns
Menses: Regular Irregular; Amenorrhea: primary Knowledge Deficit
2ndary Menopausal Heavy Flow dysmenorrhea Others___________
# of pads used during menstruation: __________
Characteristics of menses/discharge: __________________
________________________________________________
Breast: symmetry:___ discoloration:___________ MALE:
tenderrness _________ dimpling:_______________ Scrotum charac. _____________________
nodules:_________ nipple discharge______________ Testicular charac. # of Testes _______
surgically absent_______________________________ descended undescended
External Genitalia: Excoriations Rash Displaced Meatus (Hypospadia/Epispadia)
Lesions________ Vesicles Inflammation Erectile Dysfunction: yes no priapism
Discharge Charac.:____________________________ Penile Discharge: Characteristics:
Screening Methods: BSE CBE Mammography _____________________________
others:__________________________________________ Hernia: __umbilical __inguinal
Pap Smear (last pap smear) _________________ Phimosis hydrocele varicocele
Results: ______________________________________ others:______________________
______________________________________________ Screening Methods: TSE DRE PSA
others________________________________
Family Planning Use: No Yes Natural:_______ Artificial: _______ Since when __________
Medications: _________________________________________________________________________

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DX results____________________________________________________________________________
Surgeries: ___________________________________________________________________________
INTEGUMENTARY SYSTEM Diagnosis______________________________________________ CARE CONCERNS
skin integrity
Temperature ______Turgor: good poorSx______________
thermoregulatory
Characteristics: dry moist oily diaphoresis
status
Color: pale cyanotic flushed jaundiced mottled
Risk for infection
Lesions(type):__________loc/charac._______________________
Others:_________
wounds(type)__________loc/charc_________________________
Ulcers (type)____________ loc/char________________________
infestations ___________________________________________
Others: _________________________________________________
Burns: %______ degree: ________ implants_______________
Medication/s______________________________________________
DX results_______________________________________________________________________
PSYCHOSOCIAL ASSESSMENT Diagnosis_____________________________________________ CARE CONCERNS
body image
Self-Perception/Self-Concept, body image____________________________________________________
self esteem
Aids and augmentations: _________________________________________________________________
thought alteration
Development: stage, tasks and concerns:(Erickson)_____________________________________________
perceptual alteration
Expectations and concerns about hospitalization: _____________________________________________
Fear
Effects of hospitalization/illness to self:_____________________ work: _________________________
Anxiety
family: ________________________________ social life:___________________________________
Powerlessness
Learning needs:________________________________________________________________________
Hopelessness
Mood: depressed expansive irritable euphoric mood swings others_________________
Sleep pattern
Affect: apathy flat blunted restricted labile others ______________________________
disturbance
Thought: content _________________ process ____________________ flow__________________
Ineffective coping
Perception: delusion_________ hallucination __________ illusion ____________ others ________
Impaired adjustment
Motor: hypoactive hyperactive others_________ OTHERS: anxiety_________ ambivalence
Family needs
Behavior: Appropriate to situation? Yes No, describe:________________________________________
Parenting needs
Sleep: difficulty falling asleep not rested after sleep aids to sleep: ___________ meds____________
Spiritual needs
Communication pattern: non- verbal verbal. Spec__________________________________________
Cultural needs
Stress-Coping pattern? Sources of stress: ___________________ways of coping: ___________________
Suicide risk
Availability of support? : source:____________________ adequacy: _______________________________
Role conflict
Role-relationship pattern: (describe role, interaction pattern and concerns)
Sadness
a. Family: ______________________________________________________________________________
Depression
b. Work : _______________________________________________________________________________
Others:_________
c. Community: ___________________________________________________________________________
Sexuality and sexual concerns? Sex Preference:_________ Sexual problems: _____________________
Aids to sex performance:____________________________ others_____________________________
Social history : lives alone lives with: __________________________________________________
Lifestyle risk: Smoking, pack years ________ tobacco use: chew ___ smoke ____
Alcohol use; amount:_________how long?__________
betel nut chewing: length of use:______ social drug Type? ____________ Frequency? ____________
Financial concerns(describe)_______________________________________________________________
Housing concerns: _______________________________________________________________________
Legal concerns: _________________________________________________________________________
Cultural/religious practice important to client during hospitalization?_________________________________
Any advance directives? yes, specify: _____________________ No Need for more information
Other concerns: ________________________________________________________________________

I do hereby certify that all information written on this assessment tool are true and correct.

Name of the Student _______________________________ Signature _____________________ Date ____________

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