MS Tool-Long

SAINT LOUIS UNIVERSITY Excessive grogginess: _________
SCHOOL OF NURSING Bedtime rituals: _________________________________________

Relaxation techniques: ___________________________________
ASSESSMENT TOOL Sleeps on more than one pillow: ___________________________
Oxygen use (type): ______________________________________
GENERAL INFORMATION When used: ____________________________________________
Medications/ herbals for/affecting sleep:
Name: ________________________________________________ _______________________________________________________
_______________________________________________________
Age: ____ Birthdate: _________________ Objective (Exhibits)
Address: ______________________________________________ Observed response to activity
Admission: Date:_____ Time: _________ Specific activity:
From: Home: _________________________________________ ________________________________________
Hospital: _______________________________________ Before Activity Immediately after After 5 minutes
Others: ________________________________________ HR
RR
HEALTH HISTORY
BP
Reason for this visit (chief complaint):
_______________________________________________________ Pulse oximetry: __________
History of Present Illness: Mental status (e.g. cognitive impairment/ withdrawn/ lethargic):
_______________________________________________________ _______________________________________________________
_______________________________________________________ Muscle mass/ tone (e.g. normal, flaccid, hypertonic, hypotonic,
_______________________________________________________ spastic, rigid) __________________________________________
_______________________________________________________ Posture (e.g. normal, stooped, curved spine):
_______________________________________________________ _______________________________________________________
_______________________________________________________ Tremors: ______ Location: _______________________________
History of Past Surgeries/ Hospitalizations:
_______________________________________________________
_______________________________________________________ ROM: Describe: __________________
_______________________________________________________ _______________________________
_______________________________________________________ _______________________________
_______________________________________________________ _______________________________
_______________________________________________________
Diagnoses/ Impressions:
_______________________________________________________
_______________________________________________________ Strength:
_______________________________________________________
Source of Information: ___________________________________
Date:___________________
ACTIVITY/ REST Uses Mobility Aid/s: _____________________________________

Subjective (Reports) Nursing Diagnosis: ______________________________________
Occupation:____________________________________________ _______________________________________________________
Able to participate in usual activities/ hobbies: _______________________________________________________
_______________________________________________________
_______________________________________________________ CIRCULATION
Subjective (Reports)
Leisure time/ diversional activities: History of/ Treatment for (date):
_______________________________________________________ High blood pressure: ________________________________
_______________________________________________________ Head injury: __________________________________________
Ambulatory:_____________ Stroke: ______________________________________________
Gait (describe):__________________________________________ Hemoptysis: __________________________________________
_______________________________________________________ Heart Problem/surgery: _________________________________
_______________________________________________________ Syncope: _____________________________________________
Activity level (sedentary to very active): Spinal cord injury/ dysreflexia: ___________________________
_______________________________________________________ Palpitations:__________________________________________
Daily exercise (type): ____________________________________ Bleeding tendencies’ episodes: _________________________
Muscle mass/ tone/ strength (e.g normal, increased, decreased): Specify: ____________________________________________
_______________________________________________________ Varicosities: __________________________________________
_______________________________________________________ Heart problems/ Surgery: _______________________________
History of problems/ limitations imposed by condition (e.g. immobility, Thrombophlebitis: ____________________________________
can’t transfer, weakness, breathlessness): Pain in legs with activity: _______________________________
_______________________________________________________ Extremities: Numbness:_____ Location: ___________________
_______________________________________________________ Tingling: ____ Location: _______________________________
_______________________________________________________ Slow healing: sight (describe): ____________________________
Feelings (e.g. exhaustion, restlessness, can’t concentrate _______________________________________________________
dissatisfaction): ________________________________________ Medication/herbals: _____________________________________
_______________________________________________________ Objective (Exhibits)
Sleep: Hours ___________________ Naps: _________________ Color:Skin:_____________ Mucous membrane: _____________
Insomnia:________________ Type: _________________ Lips:_________________ Sclera: ________________________
Rested on awakening: ________ Conjunctiva: ________________ Nailbeds: ________________
1
Skin moisture (e.g. dry, diaphoretic): _____________________ Desires clergy visit: _____________________________________
Blood pressure: lying: R: _______ L ___________ Expression of sense of connectedness/ harmony with self and
Standing: R: _______ L ___________ others: ________________________________________________
Medications/ Herbals: ___________________________________
Pulse pressure: _______________________________________ _______________________________________________________
Objective (Exhibits)
Auscultatory gap: ____________________________________ Emotional status (check those that apply):
Calm: ______ Anxious:_________ Angry: _______________
Pulses: Carotid: ___________ Withdrawn: __________ Fearful: ______Irritable: __________
Describe: ___________________________________________ Restive: ________ Euphoric: ___________
Temporal:__________ Observed body language (e.g. pacing, fidgeting):
Describe:____________________________________________ _______________________________________________________
Brachial: __________ _______________________________________________________
Describe: ___________________________________________ Observed physiological response (e.g. pallor, flushing):
Radial: ____________ _______________________________________________________
Describe:____________________________________________ _______________________________________________________
Ulnar: _____________ Nursing Diagnosis: ______________________________________
Describe: _____________________________________ _______________________________________________________
Dorsalis pedis: ___________ _______________________________________________________
If dorsalis pedis absent or abnormal, post ELIMINATION
tibial:__________________________________________ Subjective (Reports)
If post-tibial pulse absent or abnormal, popliteal: Usual bowel elimination pattern: _____________
_______________________________________________ Character of stool: ______ Color of stool: ___ ___
If popliteal pulse absent or abnormal, femoral: Date of last BM and character of stool: (describe):
_______________________________________________ _______________________________________________________
Cardiac(palpation):thrill ______ heaves: ______ _______________________________________________________
Heart sounds (auscultation): History of bleeding (describe): ____________________________
Rate:_________ Rhythm: _____________ Quality: ___________ _______________________________________________________
Friction rub: _________ Hemorrhoids/ Fistula: __________________________________
Murmur (describe location/ sounds): Constipation: acute: _________ chronic: _________________
_______________________________________________________ Diarrhea: acute: __________ chronic: _________________
_______________________________________________________ Bowel incontinence:___________________________________
Vascular bruit (location): ____________________ Laxative: _______ how often: ________________________
Jugular vein distention: _____________________ Enema/ suppository: ___________ how often: ______________
Breath sounds: location: _____________________ Usual voiding pattern and character of urine: ________________
Description: ____________________________________________ _______________________________________________________
Extremities: Difficulty voiding: _____________________________________
temperature: ________ color:________ capillary refill: _______ Urgency: _____________________________________________
Homan’s sign: _____________ Bladder spasm: _______________________________________
varicosities (location): __________________________________ Frequency:___________________________________________
Nail abnormalities: _____________________________________ Retention: ___________________________________________
edema(location/ severity +1to+4): ________________________ Burning: _____________________________________________
Distribution/ quality of hair: _____________________________ Urinary incontinence (type/ time of day when it usually occurs):
_____________________________________________________ _______________________________________________________
Skin lesions: type:_____________________________________ _______________________________________________________
location: ____________________________________________ History of kidney/ bladder disease: _______________________
color:_______________________________________________ _______________________________________________________
Nursing Diagnosis: Diuretic use: ________
_______________________________________________________ Meds/Herbal:___________________________________________
_______________________________________________________ _______________________________________________________
_______________________________________________________ Objective (Exhibits)
Abdomen (palpation): Soft/ firm: __________________________
EGO INTEGRITY Tenderness/pain (quadrant/ location: _______________________
Subjective (Reports) Distention: __________ Palpable mass/ location: __________
Marital status: __________________________________________ _______________________________________________________
Expression of concerns (e.g. financial, lifestyle or role changes): size/ girth: _____________________________________________
_______________________________________________________ Abdomen (auscultation): bowel sounds (location/ type):
Stress factors: __________________________________________ _______________________________________________________
Usual ways of handling stress: ____________________________ Costovertebral Angle tenderness: _________________________
Ways of expressing feelings: Bladder palpable: _______________________________________
Anger: _______________________________________________ Hemorrhoids/ fistulas: ___________________________________
Anxiety: ______________________________________________ Presence/ use of cathether or continence devices:
Fear: ________________________________________________ _______________________________________________________
Grief: ________________________________________________ Ostomy devices (describe appliance and location):
Others (hopelessness, helplessness, powerlessness): ______ _______________________________________________________
_____________________________________________________ Nursing Diagnosis: ______________________________________
Cultural factors/ ethnic ties: ______________________________ _______________________________________________________
Ethnic group: ___________________________________________ _______________________________________________________
Religious affiliation: _____________________________________ FOOD/ FLUID
Active/ Practicing: _______________________________________ Subjective (Reports)
Practices (prayer/meditation, etc.): _________________________ Usual food intake: _____________ # of meals daily:
Religious/ Spiritual concerns: _____________________________ _____snacks (# and time consumed) ______
2
Dietary pattern/ content: Can select clothing and dress self: ______
B: __________________________________________________ Needs assistance with (describe): ________________________
L: __________________________________________________ Toileting: ______________________________________________
D: __________________________________________________ Can get to toilet or commode alone: ______
Snacks: _____________________________________________ Needs assistance with (describe): ________________________
Last meal consumed/ content: ___________________________ _____________________________________________________
Food preferences: ______________________________________ Objective (Exhibits)
Food allergies/ intolerances: General appearance: Manner of dressing:
_______________________________________________________ _______________________________________________________
Cultural or religious food preparation/ concerns/ prohibitions: Grooming/ Personal habits: _______________________________
_______________________________________________________ Bath: __________________________________________________
Usual appetite: ____________________________________ Shampoo ______ Perineal Care _________
Change in appetite: ______________________________________ Oral Care _______________
Usual weight: __________Unexpected/ undesired weight loss/ gain: Condition of hair/ scalp: __________________________________
__________________________________________________ Body odor: __________
Nausea/ vomiting: _______ related to: ______________________ Use of deodorant: _______________________________________
Heartburn: _________ Indigestion: ___________ Presence of vermin (lice, scabies): _____________
related to: ______________________________________________ Nursing Diagnosis: _________________________
relieved by: ____________________________________________ _______________________________________________________
Chewing or swallowing problems: _______________________________________________________
Gag/ swallow reflex present: ______ NEUROSENSORY
Facial injury/ surgery: ____________ Subjective (Reports)
Stroke/ other neurological deficit: _______________________ History of brain injury, trauma, stroke (residual effects):
_____________________________________________________ _______________________________________________________
Diabetes:______ Fainting spells/ dizziness: ________________________________
Controlled with diet/pills/insulin: __________________________ Headaches (location/type/frequency): ______________________
Vitamin/ food supplements: ______________________________ Tingling/ numbness/ weakness (location):
Medication/ herbals: _____________________________________ _______________________________________________________
Objective (Exhibits) Seizures: ______________________________________________
Current weight: _______ Height: _____________ History or new onset seizures
Body built: ______________BMI: _____________ Type: _________Frequency: ___________ Aura: __________
Skin turgor: ___________________ Postictal state: ________________________________________
Mucous membranes (moist/ dry): _____________ How controlled: _______________________________________
Edema: generalized: _____ dependent: _____ feet/ ankles: _____ Vision:
Periorbital:_________ abdominal/ascites: __________ Loss or changes in vision: ______________________________
Breath sounds (location/ adventitious sounds): Date of last exam: _____________________________________
_______________________________________________________ Glaucoma: _________ Cataract: _________
_______________________________________________________ Eye Surgery (type/ date): ________________________________
Condition of teeth/ gums: ________________________________ Hearing loss: __________ Sudden or gradual: ______________
Dentures (full/partial): ____________________________________ Date of last exam: _____________________________________
Loose/ absent teeth/ poor dental care: ______________________ Sense of smell (changes): ________________________________
sore mouth/ gums: ______________________________________ Sense of taste (changes): ________________________________
Appearance of tongue: ___________________________________ Epistaxis: ________ Other: _______________________________
mucous membranes: ____________________________________ Objective (Exhibits)
Abdomen: bowel sounds (quadrant/ Mental status (note duration of
location): _____________________________________________ change):_______________________________________________
hernia/ masses: _______________________________________ Oriented/ disoriented: __________ Person: _______________
Urine S/A or chemstix: ___________________________________ Place: _________________ Time: _________________
Serum glucose (glucometer): ___________________________ Situation: ____________________________________________
Nursing Diagnosis: ______________________________________ Check all that apply:
_______________________________________________________ Alert: _______ Drowsy: ________ Lethargic: ______________
_______________________________________________________ Stuporous: ______ Comatose: ____Cooperative: ___________
HYGIENE
Subjective (Reports) Combative: ___________ Agitated/ restless: _____________
Ability to carry out activities of daily living: independent/ dependent Follows commands: ____________
( level 1= no assistance needed to 4= completely dependent): Delusions (describe): ____________________________________
__________ _______________________________________________________
Mobility: Assistance needed (describe): ____________________ Hallucinations (describe): _______________________________
Assistance provided by: ________________________________ _______________________________________________________
Equipment/ prosthetic devices required: __________________ Affect (describe): _______________________________________
_____________________________________________________ Speech: _______________________________________________
Memory
Feeding: _______________________________________________ Recent: ______________________________________________
Help with food preparation: ___________ Remote: _____________________________________________
Help with eating utensils: _____________ Glasgow Coma Scale:
Hygiene:
Get supplies: ____________
___________________________________
Wash body or body parts: _____________ Test Score
Can regulate bath water temperature: _______ EYE OPENING RESPONSE
Get in and out alone: ____________ Spontaneously 4
Preferred time of personal care/ bath: _____________________ To speech 3
Dressing: ______________ To pain 2
3
None 1
of intersecting pentagons
MOTOR RESPONSE onto a piece of paper.
Obeys 6
Localizes 5 Scoring A score of 24 or above is considered normal. 30
Withdraws 4
Abnormal flexion 3
Abnormal extension 2
None 1
VERBAL RESPONSE Deep tendon reflexes (present/ absent): ________
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible 2
None 1
TOTAL SCORE 15
Cranial Nerves Assessment (describe result)
CN 1 : ________________________________________________
CN 2: ________________________________________________
CN 3:_________________________________________________ Tremors: ________ Paralysis (R/L): _________
CN 4: ________________________________________________ Posturing: _____________________________________________
CN 5: ________________________________________________ Wears glasses: _______ Contacts: ___________
CN 6: ________________________________________________ Hearing aids: _________
CN 7: ________________________________________________ Nursing Diagnosis: ______________________________________
CN 8: ________________________________________________ _______________________________________________________
CN 9: ________________________________________________ _______________________________________________________
CN 10: _______________________________________________
CN 11: _______________________________________________ PAIN/ DISCOMFORT
CN 12: _______________________________________________ Subjective (Reports)
Mini Mental Status Examination Location: _____ Quality: _________________________________
Folstein Mini Mental Status Examination Intensity ( 1,2,3,4,5,6,7,8,9,10 ) ________________
Task Instructions Scoring
One point each for

Date "Tell me the date?" Ask for year, season, date,
5
Orientation omitted items day of week, and
month
One point each for

Place "Where are you?" Ask for state, county, town, Radiation: ____________Frequency: __________
5
Orientation omitted items. building, and floor or Precipitating factors: ____________________________________
room
Relieving factors : Pharmacologic: ________________________
Name three objects slowly One point for each Non-pharmacologic (e.g rubbing, rest, herbal) _____________
Register 3
Objects
and clearly. Ask the patient to item correctly 3 ______________________________________________________
repeat them. repeated Associated symptoms: ___________________________________
Ask the patient to count Effect on: Daily activities: ________________________________
Serial
backwards from 100 by 7. One point for each Relationships: ________________________________________
Stop after five answers. (Or correct answer (or 5 Job: _________________________________________________
Sevens
ask them to spell "world" letter)
backwards.) Enjoyment of life: _____________________________________
One point for each Grimacing: __________ Guarding affected area: ____________
Recall 3 Ask the patient to recall the
item correctly 3
Objects objects mentioned above.
remembered
Narrowed focus: ________________________________________
Emotional response (e.g crying, withdrawal, anger):
Point to your watch and ask
One point for each _______________________________________________________
Naming the patient "what is this?" 2
correct answer Vital sign changes (acute pain): BP: ________ PR: ________
Repeat with a pencil.
RR: _________
Repeating a Ask the patient to say "no ifs, One point if
1 Nursing Diagnosis: ______________________________________
Phrase ands, or buts." successful on first try _______________________________________________________
Give the patient a plain piece _______________________________________________________
of paper and say "Take this
Verbal One point for each
paper in your right hand, fold 3 RESPIRATION
Commands correct action
it in half, and put it on the
floor."
Subjective (Reports)
Dyspnea related to: ______________________ Precipitating
Written
Show the patient a piece of
One point if the factors: _________________ Relieving factors:
paper with "CLOSE YOUR 1
Commands
EYES" printed on it.
patient's eyes close ____________________
Cough (describe): __________________________ sputum
Ask the patient to write a
One point if sentence (describe character): _________________
Writing has a subject, a verb, 1 Requires suctioning_________
sentence.
and makes sense
History of (year): bronchitis: ____asthma: _____
Drawing One point if the 1 emphysema: ____tuberculosis: __ recurrent
figure has ten corners pneumonia: ______
and two intersecting
lines exposure to noxious fumes/ allergens: ___
Infectious agents/ diseases/ poisons/ pesticides:
Ask the patient to copy a pair
_______________________________________________________
4
Smoker: Yes: ___ No: ___ _____________________________________________________
Type (e.g. menthol) ________ sticks/packs per day: ________ Use seat belt regularly: ____Bike helmets: ______
No. of yrs :____________ Other safety devices: ____________________________________
Use of respiratory aids: __________________________________ Work place safety/ health issues (describe):
Oxygen (type/ frequency): ________________________________ _______________________________________________________
Medications/ herbals: ____________________________________ Currently working: ______
_______________________________________________________ Rate working conditions (e.g. safety, noise, heating, water,
_______________________________________________________ ventilation): ____________________________________________
_______________________________________________________
History of accidental injuries: _____________________________
Objective (Exhibits) _______________________________________________________
Respirations Skin problems (e.g. rashes, lesions, moles, breast lumps, enlarged
Spontaneous: Rate: __________ Depth: __________________ nodes) describe:
Assisted:__________ Parameters: ________________________ _______________________________________________________
_____________________________________________________ _______________________________________________________
O2 inhalation: _________ Type: ___________________________ _______________________________________________________
Flow Rate: ____________________________________________ Delayed healing (describe):
Chest excursion (equal/ unequal): _________________________ _______________________________________________________
Fremitus: _____________________________________________ _______________________________________________________
Use of accessory muscles: _______________________________ _______________________________________________________
Nasal flaring: _______________________ Cognitive limitations (e.g. disorientation, confusion):
Breath sounds: ________________________________________ _______________________________________________________
Egophony:muffled: ___________ clear: ___________________ Sensory limitations (e.g. impaired vision/ hearing, detecting hot/cold,
Skin/ mucous membrane color: ___________________________ taste. Smell, touch):______________________________
clubbing of fingers: _____________ _______________________________________________________
Sputum characteristics: ___________________ Pulse oximetry: Prostheses: _______Ambulatory devices: ___________________
_________ _______________________________________________________
Mentation (e.g. calm, anxious, restless): Violence (episodes/ tendencies): _______________
_______________________________________________________ _______________________________________________________
Nursing Diagnosis: ______________________________________ Objective (Exhibits)
_______________________________________________________ Body temperature:________
_______________________________________________________ Skin integrity (e.g. scars, rashes, ulcerations, ulcerations, bruises,
SAFETY blisters, burns – degree/ %, drainage) / mark location on diagram:
Subjective (Reports) __________________________________________
Allergies/ sensitivity (medications, foods, environment, latex):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Type of reaction: ________________________________________
_______________________________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
__________________________________________________
_______________________________________________________
Exposure to pollution, toxins, poisons/ pesticides, radiation (describe
reactions): ____________________________________
_______________________________________________________
_______________________________________________________
Living conditions (with whom/ location of residence):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Travelled Places: ________________________________________

_______________________________________________________
_______________________________________________________
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify): ______________________________________
Altered/ suppressed immune system (list cause):
_______________________________________________________
_______________________________________________________
_______________________________________________________
History of STD (date/ type): ______________________________ (Front) (Back)
_______________________________________________________ Musculoskeletal
test: __________________________________________________ General strength: ______________________________________
High risk behaviours: ____________________________________ Muscle tone: ________________ Gait: ____________________
_______________________________________________________ ROM: ________________________________________________
Blood transfusion/ number: ___________ Type: _____________ Paresthesia/ paralysis: _________________________________
Date: ______________________________ Results of testing (e.g. cultures, immune function, TB, hepatitis):
Reaction (describe): ___________________________________ _______________________________________________________
5
_______________________________________________________ 2nd trimester: _____________________________________
Nursing Diagnosis: _____________________________________ Diagnostic & result: _____________________________
_______________________________________________________ 3rd trimester: _____________________________________
_______________________________________________________ Diagnostic & result: _____________________________
d3) Pregnancy complications & discomforts during present
SEXUALITY (Component of Social Interaction) pregnancy(if any)- nausea and vomiting: _______________
Subjective (Reports) loss of appetite: ______ edema: ________ UTI : ________
Sexually active: _________ co morbid illness: ______ Vag’l bleeding: ____________
STI/ Birth control method: ________________________________ abnormal weight change: ______ HPN: _______
Sexual concerns/ difficulties (e.g. pain, relationship, role): d4) Was pregnancy planned: Yes: ______ No: ______
_______________________________________________________ when was quickening felt: __________________________
Recent change in frequency/ interest: attitude of father: __________________________________
_______________________________________________________ place where mother plans to give birth: _______________
FEMALE: Subjective (Reports) _________________________________________________
Menstruation Gynecologic History:
Age at menarche: __________________ a.) Surgery affecting the: breast: _____ Mastectomy: _______
Length of cycle: ____________________ hysterectomy: _____ Hysterectomy: ______ TAHBSO :
Duration: __________________________ b.) Ectopic pregnancy: _______
Number of pads/ tampons used/ day: _________ c.) Reproductive tract diseases: PID: ______
Last menstrual period: _______________ Polycystic ovarian disease: ______ H-mole : _____
Bleeding between periods: ____________ Others: specify: __________________________________
Reproductive Infertility concerns: __________________________ d.)Breast:(symmetrical): ______ size and shape ______
Type of therapy (hormones): ______________________________ retractions/ dimpling: ______ nipple discharge: _______
Pregnant now: _________ G: _____ P: _____ (TPAL): ________ redness of the skin: _____ visible superficial veins_____
EDD: ________________________________________________ lumps or masses on both breasts: _______ axillary lymph
History of Present Condition: (Start, list and describe symptoms node mass: _____ tenderness: __________
chronologically from time/day of onset onwards) d.) Abdomen: (minimal) gravidarum striae: _______
Initial: Wt: ________ (protruded) umbilicus______ fundic height: __________
Vital signs: BP= _______ HR= ______ RR= ________ tenderness: _______ (occasional/mild) uterine contractions:
Temp. _______ ________ fetal movement ______________
Age of Gestation: _______________
bowel sounds:
no. per minute
Labor
1.Abdominal Status: FU: _____ EFW: ________ AOG: _________
a) Presence of uterine contraction: *Leopold’s Maneuver:findings: describe:
frequency duration interval intensity LM I: __________________________________________
_______________________________________________
_______________________________________________
b) IE Result: LM II: __________________________________________
_______________________________________________
time Dilat’n Efface’t BOW station discharges Done By _______________________________________________
Cond. LM III: _________________________________________
_______________________________________________
_______________________________________________
Past Medical History LM IV: _________________________________________
a.) Includes childhood illnesses (mumps, measles, german _______________________________________________
measles, poliomyelitis, etc) ________________________ _______________________________________________
__________________________________________________
__________________________________________________ e.) Genitourinary tract:
(Darkly pigmented) inguinal region: _________________
b) Any previous health care contacts- Include diagnostic test vaginal secretions (watery or bloody): _______________
results and date : u/a, cbc, bld. Typing, glucose screening presence of haemorrhoids: ________________________
test, utz result: ______________________________________ f.) Extremities: symmetrical length: _____________________
___________________________________________________ size upper and lower extremities: ___________________
c) Allergy- include food and drug hypersensitivity___________ edema: _______ varicosity: _____ limitation of ROM____
___________________________________________________ swelling of joints: ______ peripheral pulses: __________
d) Use of OTC/prescribed drugs __________________________ tenderness: ______ claudication: ___________________
___________________________________________________ g.) Integumentary: gravidarum striae-: ____________________
e) Past pregnancies: specify location: ______ lesions: ______ rashes: ______
hematoma/petechiae: _____ chloasma: ______________
No. Of Yr Method Place of del./attended Birth wt Cond’n Condn of
Preg. of Del. by baby
Post Partum
h.) Abdominal status:
location and size of the uterus: ______________________
Prenatal History condition of the uterus: ____________________________
d1) General physical and emotional state of the mother during i.)GUT status:presence of vaginal discharge: __________
pregnancy ________________________________________ amount: ____________ color: _______________________
__________________________________________________ condition of the perineum ( particularly if episiotomy is
d2) Prenatal check up/consultations: done):____________________________________________
1st trimester (frequency):___________________________ functioning of the bladder (time and amount of first urine, time
Diagnostic & result: _____________________________ of first BM postpartum)_________________________
6
_________________________________________________ Communication/ speech: Clear: ______ Slurred: _______
j.) Emotional/ Psychological Status Unintelligible: _____ Aphasic: ______
postpartum blues: ________ depression: _____________ Unusual speech pattern/ impairment: _____
heightened emotional reactions/labile moods: _________ Laryngectomy present: _____
_________________________________________________ Family interaction (behavioural pattern)_____________________
_______________________________________________________
Menopause: _____ onset: ____________ Nursing Diagnosis: _____________________________________
Hysterectomy/ Oophorectomy: ____________________________ _______________________________________________________
Problem with: Vaginal lubrication: _____ hot flushes: ________ _______________________________________________________
Vaginal discharge: ______ others: ________________________ TEACHING/ LEARNING
Hormonal therapies: ___________________________________ Subjective (Reports)
Osteoporosis medications: ______________________________ Communication Dominant Language (specify):
Practices BSE: ____ Last mammogram: ____________________ _______________________________________________________
Last Pap smear: _________ Results: _______________________ Second language: _______________________________________
Objective (Exhibits) Literate (reading/ writing): ______________
Genitalia (warts/ lesions): _______ Educational level: _____________________________________
STI test results: _________________________________________ Learning disabilities (specify): ___________________________
vaginal bleeding/ discharge: ________ Cognitive limitations: ____________________________________
Management: Meds: prescribed:___________________________ Ethnic Affiliation: __________________________
_______________________________________________________ Health and illness beliefs/practices/ customs: _______________
Nursing Diagnosis: ______________________________________ _______________________________________________________
_______________________________________________________ Which family member makes healthcare decisions/ is spokesperson
_______________________________________________________ for client: _________________________________
_______________________________________________________ Presence of Advanced directives: _______ Code status: _______
Durable medical power of attorney: ___________
MALE: Subjective (Reports) Designee: ____________________________________________
Circumcised: ________ Health goals: ___________________________________________
Practices self examination: Breast: _________ Current health problem: client understanding of problem:
testicles: ________ _______________________________________________________
Prostate disorder: _________ _______________________________________________________
last prostocopic/ prostate exam: ____________ Special health concerns (e.g. impact of religious/ cultural practices):
last PSA date: ______________ _____________________________________________
Medications/ herbals: ____________________________________ _______________________________________________________
Genitalia: Penis (circumcised): _______ warts/ lesions: ______
bleeding/ discharge: _______ Familial risk factors (indicate relationship):
Testicles (e.g. lumps): ________ Breast examination: ________ Diabetes: _____________ Thyroid (specify): ____________
STI test results: _________________________________________ Tuberculosis: ____________ Heart disease: __________
_______________________________________________________ Stroke: __________________ Hypertension: ____________
Nursing Diagnosis: ______________________________________ Cancer: ________________ Kidney disease: ____________
_______________________________________________________ Epilepsy/ seizures: ________
_______________________________________________________ Mental illness/ depression: ___________
others: _______________________________________________
SOCIAL INTERACTIONS Vitamins: _________________ Herbals: ____________________
Subjective (Reports) Street drugs: _________
Relationship status: Single: _____ Married: _______ Alcohol (amount/ frequency): ______________ Tobacco: ______
Separated/ Annulled/ Divorced: ________ Widowed: ______ Smokeless tobacco: ______
Living with (Specify): ____________________________________ Expectations of this hospitalization:
Yrs of Relationship:__________ _______________________________________________________
Perception of relationship: _______________________________ Will admission cause any lifestyle changes (describe):
Concerns/ stresses: _____________________________________ _______________________________________________________
Role within family structure: ______________________________ _______________________________________________________
Number/ Age of children: __________________ _______________________________________________________
Perception of relationship with family members: _____________ Evidence of failure to improve: ____________________________
_______________________________________________________ _______________________________________________________
Extended family: ________________________________________ Date of last physical exam: _______________________________
other support persons: __________________________________ Nursing Diagnosis: _____________________________________
Ethnic/ Cultural affiliations: _______________________________ _______________________________________________________
Strength of ethnic identity: _______________________________ _______________________________________________________
Feelings of (describe):
Mistrust: _____________________________________________ DISCHARGE PLAN CONSIDERATIONS
Rejection: ____________________________________________ Projected length of stay: ___________________ Anticipated date of
Unhappiness: _________________________________________ discharge:_______________
Loneliness/ Isolation: __________________________________ Date information obtained: ___________
Problems related to illness/ condition: ______________________ Resources available
Problems with communication (e.g. speech, another language, brain Persons: _____________________________________________
injury): ___________________________________________ financial: _____________________________________________
Use of speech/ communication (list)_______________________ Community support: ___________________________________
_______________________________________________________ Groups: ______________________________________________
Is interpreter needed:Yes ______ No ______ Areas that may require alteration/ assistance:
Primary language: _________________________ Food preparation: _________________
Objective (Exhibits) Shopping: _______________________
7
Transportation: ___________________
Ambulation: ______________________
Medication/ IV therapy: _____________
Treatments: ______________________
Wound care: ______________________
Supplies: _________________________
Homemaker/ maintenance (specify):
_______________________________________________________
Physical layout of home (specify):
_______________________________________________________
Referrals (date/ source/ services)
Social services: _______________________________________
Rehab services: _______________________________________
Dietary: ______________________________________________
Home care: ___________________________________________
Respiratory/ O2: _______________________________________
Equipment: ___________________________________________
Supplies: _____________________________________________
Other: _______________________________________________
8
9
10

MS Tool-Long

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MS Tool-Long

Uploaded by

Copyright:

Available Formats

SAINT LOUIS UNIVERSITY Excessive grogginess: _________

SCHOOL OF NURSING Bedtime rituals: _________________________________________

ACTIVITY/ REST Uses Mobility Aid/s: _____________________________________

One point each for

One point each for

Travelled Places: ________________________________________

You might also like