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BSU College of Nursing Assessment Form

BSU College of Nursing Assessment Form

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Published by Lucille Allen
Bukidnon State University College of nursing currently followed assessment form for nursing students.
Bukidnon State University College of nursing currently followed assessment form for nursing students.

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Published by: Lucille Allen on Aug 04, 2008
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07/11/2013

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BUKIDNON STATE UNIVERSITY
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:
 _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  _______ 
Has received blood in the past?
Yes _____No ______ if yes, list dates_________________ 
Blood reactions if any:
______________________________________________________________________  _________________________________________________________________________________________  _ 
Allergies:
Food: ______________________________________________________________________________ Medications: _________________________________________________________________________ 
Admitting Diagnosis:
 _________________________________________________________________________________________  _  _________________________________________________________________________________________  _________________________________________________________________________________________  _________________________________________________________________________________________  ___ 
Attending Physician:
_________________________________________________ 
Consultant: _________________________________________________________ 
1
 
II. NURSING ASSESSMENT
A.
DIGESTIVE/METABOLIC/NUTRITION
 Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.
Objective SubjectiveGeneral Appearance:
Alert/responsive
Apathetic
Cachexia
Abdominal Distention
Mass
Tenderness/pain
Skin
:
Dry
Warm
Cold
Moist
EdemaTurgor: ____________________________________ 
Eyeball:
Sunken
Moist
Dry
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
Loss of Appetite
:
Anorexia
BulimiaBody weight: _____________kg
Usual Diet:
___________________________________  No. of meals per day: ___________ (3x a day) No. of fluid drink each day: _______(8-12 glasses/day) 
Alcohol and Beverages ________________________ Undesired Weight loss:
Yes
 NoUndesired Weight gain:
Yes
 No
Food restrictions R/T intolerance and healthproblems or religious practices?
 _____________________________________________  _____________________________________________ 
Difficulty in eating and swallowing:
 _____________________________________________  _____________________________________________ 
Previous/Recent Illness:
Diabetic
Hyperthyroidism
Hypothyroidism
Colon Cancer 
Abdominal PainComment:
___________________________________  _____________________________________________  _____________________________________________ Elimination pattern:
Diarrhea
Constipation
 
Frequency of BM:______________/day
Remarks: _________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________ 
2
 
Nursing Diagnosis: _________________________________________________________________________________________  _  _________________________________________________________________________________________  _ B. RESPIRATORY SYSTEM
 Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective SubjectiveBreath Sounds:
Diminished/Absent
Stridor 
Rales/Crackles
Rhonchi/Wheezing
Normal (Vesicular, Bronchovesicular, Bronchial)
 None (atelectasis)
Resonance:
Hyper 
Hypo
Respiration/Oxygenation:
 Normal(Relax, Effortless and Quiet)
Labored/Use accessory Muscle]
Dyspnea
Tachypnea
Bradypnea
Cyanosis
Pallor 
Cheyne-stoke
Biot’s
 
Hyperventilation
Hypoventilation
 Nasal Flaring
Pursed lip
Barrel Chest
Pleuritic Pain
O2 Inhalation _____liters/minRate: ________________________ 
Tube/Drainage:
 
CTT
Oral Airway
 
Endotracheal Tube
Ventilator 
Cough:
Productive
 Non-productive
Sputum:
 
Mucoid
Bloody (hemoptysis)
Rusty
Frothy
Thick Tenacious
 
Color: ____________________________ 
Previous/Recent Illnesses:
Bronchitis
Emphysema
Asthma
Brochiectasis
Pneumonia
Hydrothorax
Pneumothorax
Hemothorax
CHF
Chest Trauma
Lung Cancer Comment: ____________________________________  _____________________________________________  _____________________________________________  _____________________________________________ 
Breathing Treatments/Medication: ______________  _____________________________________________  _____________________________________________  _____________________________________________ Smoking:
Yes For how long: __________ 
 NoComment
:____________________________________  _____________________________________________  _____________________________________________  _____________________________________________  _____________________________________________ Remarks: _________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________  __________________________________________________________________________________________ Nursing Diagnosis: _________________________________________________________________________________________  _ 
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