CAPITOL UNIVERSITY

College of Nursing

NURSING ASSESSMENT FORM

A. Demographic Data

Name of Client _________________________________________ Unit/Ward __________ Bed ________

Age _________ Sex _________ Civil Status _____________ Religion ___________________________
Date of Admission _______________________ Medical Diagnosis ____________________________________________
Examiner ________________________________ Information given by ________________________________________

B. Vital Signs

Temp ___________ oral axilla rectal BP ___________  lying  sitting  standing

Pulse ___________/ min.  regular  irregular Resp ___________/ min.  regular  irregular
Height ___________ cm. Weight ____________ kg.

C. Health Patterns Assessment: Complete information, including patient’s words. Indicate N/A if non-applicable. Circle,
code, or check all findings as appropriate.

1. Health Perception and Health Management Pattern

Reason for hospitalization/chief complaint ________________________________________________________________
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History of present illness ______________________________________________________________________________
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Previous hospitalizations/surgeries_________________________________________________________________________
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What other health problems have you had? __________________________________________________________________
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Things done to manage health ____________________________________________________________________________
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Statement of patient’s general appearance ___________________________________________________________________
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Tobacco use:  Yes  No Used to smoke ______________ packs/day for __________ years
Alcohol use:  Yes  No Amount: _______________ Frequency: _________________ Duration: _____________
Coffee/Cola/Tea Intake:  Yes  No Amount: ___________ Frequency: ____________ Duration: _____________
Recreational/Illicit Drug use:  Yes Specify: _____________________  No
Allergies:  Yes (list with reaction experienced)  No
Food: __________________________________________ Medications:_____________________________________
Others: ________________________________________________________________________________________

Medications:
NAME DOSE SCHEDULE INDICATIONS

Have you been taking your medication(s) as prescribed? ________________________________________________________

OTHER PERTINENT DATA: _____________________________________________________________________________
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 2. Nutrition and Metabolic Pattern
Special diet? _____________________________________________ Supplements: ________________________________
Pattern of daily food/fluid intake (describe amount/quantity) ____________________________________________________
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Appetite: ________________________________________________ Wt. loss/gain? ________________________________
Nausea/Vomiting: _________________________________________  Hematemesis  Coffee-ground vomitus

Food/eating discomforts________________________________ GI pain ___________________________________________

Nutritional state:  well-nourished  poorly nourished  obesity  cachexia

Mouth: Lips:  pinkish  pallor  cyanosis  dryness/cracks  lesions: ________________________________

Mucosa:  pinkish  pallor  cyanosis
Tongue:  midline  R/L deviation  atrophy  fasciculation
Teeth:  complete  missing teeth  caries  dentures: ________________
Gums:  pinkish  pallor  bleeding  tenderness

Pharynx: Uvula:  midline  R/L deviation Mucosa:  pinkish  pallor  reddish

Tonsils:  not inflamed  R/L inflamed  R/L with exudate
Posterior Pharynx:  inflammation/congestion

Neck: Trachea:  midline R/L deviation Cervical lymph nodes:  lymphadenopathy  tenderness
Thyroids:  non-palpable  enlarged Others:  neck enlargement  normal ROM  neck rigidity

Skin: General Color:  pinkish  pallor  jaundice  dusky  cyanotic  flushed  mottled
Texture:  smooth  rough  others: __________________________
Turgor:  supple  firm  dehydrated  others: ___________________________
Temperature:  warm  cool  others: ______________ Moisture:  dry moist/clammy  oily
Others:  petechiae  ecchymosis  hematoma lesions/rashes: ____________________________________
 edema: ____ pitting ____ non-pitting ____ pedal: R/L ______ bipedal Grading: ____________

Wounds/drains/dressings: _________________________________________________________________________________
Intravenous fluids _______________________________________________________________________________________
OTHER PERTINENT DATA: _____________________________________________________________________________
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3. Elimination Pattern
Usual bowel pattern (describe character of stool, frequency, discomforts) ___________________________________________
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_________________________________________________________________ Date of last BM: ______________________
 Melena  Hematochezia
Any problems with hemorrhoids/incontinence? _______________________________________________________________
Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies” anti-diarrheals): _______________
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Abdomen: General :  superficial veins  straie  scars/lesions: ____________________

Configuration:  symmetrical  asymmetrical  flat  globular  protuberant  scaphoid
Bowel Sounds:  normoactive  hyperactive  hypoactive  absent
Percussion:  tympanitic  hypertympanitic  dullness at _________________________________
 fluid wave  shifting dullness
Palpation:  muscle guarding  direct tenderness  rebound tenderness  bladder distention
 organomegaly: ___ liver ___ spleen  masses at _____________________________________

Usual urinary pattern (describe frequency, character, amount, problem in control, etc.) ________________________________
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 dysuria  hematuria  nocturia  retention  flank pain  polyuria  oliguria anuria
Excess perspiration/nocturnal sweats: _______________________________________________________________________
OTHER PERTINENT DATA: _____________________________________________________________________________
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4. Activity – Exercise Pattern

Exercise Pattern? (Type, Regularity) _______________________________________________________________________
Leisure Activities? _____________________________________________________________________________________

Cardiovascular Status:  chest pain/radiation: _______________________  palpitations  dyspnea on exertion

 orthopnea  paroxysmal nocturnal dyspnea  jugular vein distention
Precordial area:  flat  bulging  tenderness  heave  thrill
Point of Maximal Impulse (PMI) _____________________ Apical rate & rhythm _____________________________
Heart Sounds: distinct  regular  faint  irregular S1 < > S2 at the base S1 < > at the apex
Others:  S3  S4  Murmur best heard at ________________  Pericardial rub
 Peripheral pulses:  symmetrical  regular  absent  faint/weak  strong  bounding
Capillary refill __________________________  clubbing
Presence of Pacemaker/A-V Shunt/Hemodynamic monitoring ______________________________________________

Respiratory Status: Breathing Pattern:  regular  irregular  eupnea  hyperpnea  tachypnea  bradypnea
 dyspnea: rest / exertion  use of accessory muscles  ICS retractions/bulging  pain on respiration
Shape of Chest: Anterior-Posterior-Lateral Ratio AP_____: L_____  barrel chest  funnel  pigeon
Lung Expansion:  symmetrical  R / L decreased/lag
Vocal/Tactile Fremitus:  symmetrical  decreased / increased at _________________
Percussion:  resonant  dullness at ___________________  hyperresonant at ___________________
Breath Sounds:  vesicular  bronchovesicular at _________________  bronchial at __________________
 rales/crackles at______________  wheezes at ___________________  rhonchi  pleural friction rub
Cough:  productive  non-productive Sputum: color _________ amount________ consistency __________

O2 supplement/ventilatory assistance_______________________________________________________________________
Resp. tubes (e.g. ET, trach, chest tube – describe secretions/drainage)_____________________________________________
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Activities of Daily Living/ Mobility Status: Use the Activity Level Code below to assess ADL & mobility status
ADL Status Mobility Status
0 – total independence Feeding ________ Meal Preparation_____ Bed mobility _____________
1 – assist with device Bathing ________ Cleaning __________ Chair/toilet transfer________
2 – assist with person Dressing _______ Laundry __________ Ambulation ______________
3 – assist with device & person Grooming ______ Toileting __________ R.O.M. _________________
4 – total dependence
Reasons for ADL/Mobility limitation _______________________________________________________________________
Device used for assistance ________________________________________________________________________________
Exercise pattern (describe type, regularity) ___________________________________________________________________

Back and Extremities: Range of Motion:  full  symmetrical  decreased ROM (specify joint) _________________
 Joint tenderness/pain  joint swelling at ________________  varicose veins  deformities _____________
Muscle tone and Strength:  equally strong  symmetrical in size  R / L Upper / Lower Atrophy
 R / L Upper / Lower Paresis  R / L Upper / Lower Paralysis
Spine:  midline  Kyphosis  Lordosis  Scoliosis
Gait:  coordinated  smooth  uncoordinated  shuffling  staggering
OTHER PERTINENT DATA _____________________________________________________________________________
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5. Cognitive – Perceptual Pattern

Level of Consciousness:  conscious  alert  confused  drowsy  stuporous  comatose  others_______

Orientation:  oriented  disoriented to : time / person / place
Emotional state:  calm  worried/anxious  restless  others: ______________________________________
Appropriate behavior/communication: ______________________________________________________________________
 dizziness  numbness  tingling sensation

Head:  normocephalic  asymmetrical  enlarged  masses: _____________  others: ___________________

Facial Movements:  symmetrical  asymmetrical: lag at R / L
Fontanels:  closed  sunken  bulging  open: specify _____________________
Hair:  fine  coarse  dry  normal/even distribution  alopecia
Scalp:  clean  dandruff  lice  wounds/scars/lesions: specify_______________________________

Eyes: Lids:  symmetrical  R / L edema/swelling  R / L ptosis  lesions: __________________________

Periorbital region:  edema  sunken  discoloration
Conjunctiva:  pink  pale  lesions  discharges
Cornea & Lens:  opacity: R / L  lesions: __________
Sclera:  anicteric  subicteric icteric  hemorrhages
Pupils:  equal: size _____mm.  unequal: R= _____mm. L= _____mm.
Reaction to Light: R -  brisk  sluggish  fixed L -  brisk  sluggish  fixed
Reaction to Accommodation:  uniform constriction / convergence  unequal constriction / convergence
Visual Acuity:  grossly normal  farsighted  nearsighted  wears eyeglasses/contact lenses
Peripheral Vision:  intact/full  decreased/ limited: _________________________

Ears: External Pinnae:  normoset  symmetrical  tenderness  lesions  gross abnormalities ______________
External Canal:  discharge: ___foul smelling ___ serous ___ purulent ___mucoid  Cerumen: ____impacted
Tympanic Membrane:  intact
Gross Hearing:  normal  decreased  symmetrical  R / L deafness

Nose:  alar flaring  shallow nasolabial fold Septum:  midline  deviated  perforated
 Mucosa:  pinkish  pale  reddish Discharge:  serous  mucoid  purulent  bloody
Patency:  both patent  R / L obstruction  masses/lesions: describe __________________________________

Gross Smell:  normal/symmetrical  R / L olfactory deficiency

Sinuses:  tenderness: ____ maxillary ____ frontal

Cognition: Primary language _________________________ Speech deficit _____________________________________

Educational attainment ______________________________________________________________________________
Any learning difficulties? ____________________________________________________________________________
Any change in memory lately? ________________________________________________________________________

Pain:  no problem  problem ( describe location, type, intensity, onset, duration of pain) ________________________
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Methods of pain management: ________________________________________________________________________

6. Sleep – Rest Pattern

Usual sleep/rest pattern: _______________________________________________________________________________

Adequate  yes  no Factors affecting sleep/rest: ______________________________________________________
Methods to promote sleep _____________________________________________________________________________
History of sleep disturbances ___________________________________________________________________________

7. Self-perception and Self-concept Pattern

How do you describe yourself ? ________________________________________________________________________
Are there any ways you feel differently about yourself since you’ve been ill/hospitalized? __________________________
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Description of non-verbal behaviors: ____________________________________________________________________
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8. Role – Relationship Pattern

Marital status _____________ Age and health of significant other _____________________________________________
Age and health of children ____________________________________________________________________________
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Illnesses in the family ________________________________________________________________________________
Live  alone  family  others: ___________________________________________________________________
Family feelings regarding illness/hospitalization ___________________________________________________________
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Who are the people that will help you most at this time? _____________________________________________________
Occupation: (any stresses/hazards?) _____________________________________________________________________
Financial support system: ______________________________________________________________________________

9. Sexuality – Reproductive Pattern

Any changes/problems with sexual relations? ________________________________________________________________
Female: Menstrual pattern:___________________________________ Problems/changes: ____________________________
Date of LMP _________________________ Pregnancy history ____________________________________________
Use of birth control measure  yes  no  N/A Type: _____________________________________________
Any problem with use ? ______________________________ Monthly self-breast exam  yes  no
External Genitalia: Labia:  symmetrical  asymmetrical  lesions __________________
 pinkish  discoloration  edema
Urethra:  pinkish  red/inflamed Vaginal Orifice Discharge:  purulent  bloody  foul-smelling
Others:  swelling  lumps/nodules
Breast:  equal  unequal Surface:  smooth  retraction  dimpling  edema  lesions
 tenderness  masses at _____________________  others: __________________________

Male: Prostate problems? _____________________________ Monthly self-testicular exam  yes  no

Penis:  discharge ________________  nodules/growths/lesions  tenderness
Scrotum:  equal shape w/ L lower than R  non-tender  R/L enlargement  R/L undescended testes
 tenderness  nodules/growths/lesions
Others:  hernia  hydrocoele

10. Coping – Stress Tolerance Pattern

Have you experienced any recent stressful situations in addition to your illness/hospitalization?  Yes  No
If “Yes”, please describe briefly _______________________________________________________________________
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Are there any ways we can be of assistance? ______________________________________________________________
How do you usually manage stresses? ___________________________________________________________________
What do you do for relaxation? _________________________________________________________________________
Support groups/counseling resources used: _______________________________________________________________
Were they helpful? __________________________________________________________________________________

11. Value – Belief Pattern

Religion ____________________ Is it important in your life? How? __________________________________________
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Religious practices __________________________________________________________________________________
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Will illness/hospitalization interfere? ____________________________________________________________________