BUKI DN ON ST ATE UN IVE RS ITY

COLLEGE OF NURSING

ASSESSMENT TOOLS

I. DATA BASE AND HISTORY

Name of Patient: ___________________________Date of Birth: ______________ Sex: ______ Age: _______
Address: __________________________________________________________________________________
Religion: _______________________________ Civil 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:

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Has received blood in the past? Yes _____ No ______ if yes, list dates_________________

Blood reactions if any: ______________________________________________________________________

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Allergies:
Food: ______________________________________________________________________________
Medications: _________________________________________________________________________

Admitting Diagnosis:
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Attending Physician: _________________________________________________

Consultant: _________________________________________________________

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 II. NURSING ASSESSMENT
A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, and 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 □Edema
□ Alcohol and Beverages ________________________
Turgor: ____________________________________

Eyeball: □ Sunken □ Moist □Dry Undesired Weight loss: □ Yes □ No

Mouth: □ Dentures □ Braces □ Lesions
□ Cleft Palate □ Cleft Lip □ Ulcers
No. of teeth: ______________________
Tongue: □ Dry □ Moist □ Furrows
Venous filling: ________ (Normal less than 3-5 sec)
Intravenous Fluid: __________________________
Date of insertion: ____________________________
Wounds: __________________________________
Tube/Drainage: _____________________________
Vital Signs: T _____ P ______ R_______BP ______
Body Types:
□ Ectomorph □ Mesomorph □ Endomorph
□ Obese □ Thin
Undesired Weight gain: □ Yes □ No
Food restrictions R/T intolerance and health
problems or religious practices?
_____________________________________________
_____________________________________________
Difficulty in eating and swallowing:
_____________________________________________
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Previous/Recent Illness:
□ Diabetic □ Hyperthyroidism □ Hypothyroidism
□ Colon Cancer □ Abdominal Pain
Comment: ___________________________________
_____________________________________________
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Elimination pattern: □ Diarrhea □ Constipation
Frequency of BM:______________/day

Loss of Appetite: □ Anorexia □ Bulimia

Body weight: _____________kg

Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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B. RESPIRATORY SYSTEM
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 □ Hydrothorax
□ None (atelectasis) □ Pneumothorax □ Hemothorax □ CHF
□ Chest Trauma □ Lung Cancer
Resonance: □ Hyper □ Hypo 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
Rate: ________________________ □ Yes For how long: __________
Tube/Drainage: □ CTT □ Oral Airway □ No
Comment:____________________________________
□ Endotracheal Tube □ Ventilator
_____________________________________________
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Cough: □ Productive □ Non-productive _____________________________________________
Sputum: □ Mucoid □ Bloody (hemoptysis) _____________________________________________
□ Rusty □ Frothy □ Thick Tenacious
Color: ____________________________

Remarks: _________________________________________________________________________________
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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: ____________________________________
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Apical: □ Regular □ Irregular Rate: ____ _____________________________________________
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Radial Pulse: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right______ Left _______
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Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak Do you experience any of the following:
□ Strong □ Absent Rate: Right_____ Left _____
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak □
□ Chest pain □ Arm pain □ Leg pain
Strong □ Absent Rate: Right_____ Left _____ □ Joint and Back □ Dyspnea □ Orthopnea
□ Cough □ Numbness and Tingling
Heart Rhythm: □ Tachycardia □ Bradycardia □ Light headedness □ Fatigue and weakness
□ Arrhythmia/ Dysrhythmia □ Palpitations
Comment: ___________________________________
Jugular Veins Distention: _____________________________________________
□ Positive □ Negative _____________________________________________

Nail bed Color : □ Pink □ Blue □ Pale Exercises:

Type: _______________________________________
Capillary Refill: ________ (Normal less than 2 sec) Frequency: __________________________________
Duration: ____________________________________
Edema: □ Pitting □ Non Pitting
Problem experience with usual activity and exercise:
Location: _____________________________
Comment: ____________________________________
_____________________________________________
Varicosities: □ Yes □ No
Location: __________________________________ Factors Affecting Activity Intolerance:
Comment: ____________________________________
Calf Tenderness (Homan’s Sign): _____________________________________________
Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks: _________________________________________________________________________________
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__________________________________________________________________________________________
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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 _____________________________________________
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□ Acanthosis Nigricans □ Albinism □ Erythema
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□ Edema □ Petechia □ Itching □ Drainage _____________________________________________
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer Comment:____________________________________
Temperature: _________ _____________________________________________
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Hair: □ Alopecia □ Hirsutism □ Patchy hair loss
Distribution: ________________________________ Comment:____________________________________
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Nails: □ Dirty □ Pallor □ Cyanosis _____________________________________________
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□ Clubbing □ Paronychia □ Onycholysis
Capillary refill: __________ (Normal less than 2 sec)
Color: _________________

Remarks: _________________________________________________________________________________
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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
Edema: □ Yes □ No □ Residual urine (> 100ml)
Location: __________________________________ Comment: ___________________________________
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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
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___________________________________________ Physical Activity: _____________________________
___________________________________________ Comment: ___________________________________
___________________________________________ _____________________________________________

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___________________________________________ Excessive Perspiration and Odor Problem:
___________________________________________ □ Yes □ No

Consistency:
Stools: ______________________________________

Remarks: _________________________________________________________________________________
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Nursing Diagnosis: _________________________________________________________________________

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F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.
Objective Subjective
Mobility: □ Ambulatory □ Non Ambulatory Do you experience any of the following:
□ Bedridden □ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Appliance __________________________ □ Joint pain
Gait and Posture: □ Lordosis □ Kyphosis Comment ____________________________________
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□ Scoliosis □ Shaftling □ Poliomyelitis
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□ Amputated Limb ______________________

Club foot (Talipes) Comment: ___________________________________

□ Varus □ Valgus □ Equinovarus □ Calcanous _____________________________________________

□ Use of Appliance __________________________ Comment: ___________________________________

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Muscle Tone/Strength: Comment: ___________________________________
□ Normal □ Slight weakness ____________________________________________
□ Average weakness □ Poor ROM _____________________________________________
_____________________________________________
□ Severe Weakness □ Paralysis
□ Atrophy □ Hyperatrophy
□ Spasm

Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
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□ Contractures/Deformities □ Crepitus
□ Tingling/Numbness (Carpal Tunnel Syndrome)
□ Ankylosis □ Foot Drop □ Pressure Ulcers
□ Urinary Elimination changes _________________
Comment: ___________________________________
_____________________________________________
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Calf Tenderness (Homan’s Sign):

Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks: _________________________________________________________________________________
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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
□ Decorticate □ Decerebrate □ Hypertension □ Smoking □ Hx CVD
□ Sleep Apnea □ High level of Cholesterol
GCS Score: _________ □ Drug Abused □ DM □ Oral Contraceptives
□ Menopausal □ Over weight
Cushing Triad (Respiratory changes, Increase BP, Comment: ____________________________________
Decreasing level of Consciousness)
□ Positive □ Negative Do you experience any of the following:
□ Blurring □ Diplopia □ Photophobia
Sensation: □ Positive □ Negative □ pain □ Inflammation □ Cataract
□ Glaucoma □ Headache □ Unusual Discharges
Pupillary Size: □ PERRLA □ Anisocoric Comment: ____________________________________
_____________________________________________
Orientation: □ Person □ Place □Time/Date
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□ Pain

Sensory Function: □ Positive □ Negative

Location: __________________________________

Motor Function: □ 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: _________________________________________________________________________________
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Nursing Diagnosis: _________________________________________________________________________

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

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IV. NURSING CARE PLAN
DATA NURSING DX OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

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 V. DRUG STUDY
Name of Drug Dose/
Mechanism of
Generic Classification Frequency/ Indication Contraindication Side effects Nursing Precaution
action
(brand) Route

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VI. SOAPIE (First day)

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VI. SOAPIE (Second day)

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VI. SOAPIE (Third day)

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 VII. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

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VII. PATHOPHYSIOLOGY
Name of Patient: __________________________________ Age: ______________ Sex _________________
Diagnosis: ________________________________________________________________________________

Definition:

Reference:

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