PA TOOL ASSESSMENT (guides in collecting information about the patient)

PATIENT
AGE:
CIVIL
HEALTH HABITS:
NAME:
STATUS:
ADDRESS:

RELIGION:

OCCUPATIO
N:

TOBACCO:
ALCOHOL:
OTC DRUGS:

DOCTORS DIAGNOSIS: ________________________________________________________

CHIEF COMPLAINTS:
_________________________________________________________________________________
__________________________________________________________________________________________________
HOSPITAL ENVT:
____________________________________________________________________________________
__________________________________________________________________________________________________
FAMILY GENOGRAM: (with age and gender)
FATHER: ______________________________________________________
MOTHER: _____________________________________________________
SIBLINGS:________________________________________________________________________________________
__________________________________________________________________________________________________
__
VITAL SIGNS:
Time
Temp
Pulse
rate
Resp.
rate
BP
IV FLUID:
Date/Time:

MEDICATIONS:
Date/Time:

IV Fluid/Volume

Drop rates

Medications (Dosage, frequency, route)

LABORATORY/DIAGNOSTIC PROCEDURES:
Date:
Name of Procedure:

Results:

Normal Values:

GENERAL:
R/L arm:__

left IVF level:

Activity of daily living:

______________________________
Weight changes:
__________________________________
Fatigue/weak:
____________________________________
Fever/Night sweats:
_______________________________
SKIN:
Changes in color/turgor/edema:
_____________________
Rashes/Scars/moles:
_______________________________
Capillary refill (how long?):
_________________________
Itchiness/tenderness: (where?)
______________________
Nails (clean?):
____________________________________
HEAD:
Size/Symmetry:
___________________________________
Trauma/lumps/tenderness:
_________________________
Headache/head injuries:
____________________________
Alopecia/distribution:
______________________________
Oily hair/ Dry hair:
________________________________
Dandruffs:
_______________________________________
EYES:
Near/far sightedness:
______________________________
Color blindness:
__________________________________
Glaucoma/cataracts:
_______________________________
Blurring of vision/ photophobia:
_____________________
Teary eyes/itching of eyes:
__________________________
PERRLA:
_________________________________________
________________________________________________
NOSE:
Sinuses/trauma:
__________________________________
Sneezing:
________________________________________
Loss of smell:
_____________________________________
Allergies on smell:
_________________________________
TOOTH:

Toothache/no. of teeth:
____________________________
Bleeding gums/difficulty of swallowing:
_______________
Lips (dry, cracked, pinkish?):
_________________________
RESPIRATORY:
Chest pain/cough:
_________________________________
Color of sputum/rashes:
____________________________
Size (symmetrical):
________________________________
History of respiratory problems:
_____________________
CARDIOVASCULAR:
Chest pain/shortness of breath:
______________________
Hearts sounds/capillary refill:
________________________
History of heart disease:
____________________________
EXCRETORY:
Urination (color, smell, frequency, pain?):
______________
________________________________________________
Defecation (color, smell, frequency, pain?):
____________
________________________________________________
DIGESTIVE:
Abdominal pain (pain scale):
________________________
Bowel sound/vomiting:
_____________________________
Diet/lips observation:
______________________________
Appetite (eats how many times?):
____________________
MUSCULOSKELETAL:
Muscular strength scale 5/5:
________________________
Deformities:
_____________________________________
Limitations of moments:
____________________________
Hx of skeletal injuries:
______________________________
REFLEXES:
Biceps: (R) ________________ (L)
_________________
Triceps: (R) ________________ (L)
_________________
Patellar: (R) ________________ (L)
_________________
EARS:
Size/symmetry:
___________________________________
Discharges:
______________________________________

Webers Test: (+) ___________ (-) ____________

Rinnes Test: (+) ___________ (-) ____________
Acquired Diseases:
Hypercholesterolemia _____ Drug
addiction _____
Kidney disease _____ Hepatitis A ______
Tuberculosis _____
B ______
Alcoholism _____
C ______
Others
___________________________________
Heredo- familial Diseases:
Diabetes ____ Asthma _____
Heart diseases ____ Epilepsy _____
Hypertension ____ Mental Illness ____
Cancer ____ Rheumatism/Arthritis _____
Others
___________________________________
Height: _____________
Weight: _____________

Previous Tx and
Result:__________________________
____________________________________________
_
Social and vocational responsibilities:
______________
____________________________________________
_
Affected Diagnosis:
_____________________________
History of Past Illness:
Previous Hospitalization (Why?, When?):
___________
____________________________________________
_
Injuries:
______________________________________
Procedures:_________________________________
__
____________________________________________
Infectious Diseases:
____________________________
Immunization/health maintenance (like
meds and
vitamins):______________________________________
__
Major Illnesses:
_______________________________
Allergies:
_____________________________________
Medications (any maintenance
meds?):____________
____________________________________________
_
Habits:
______________________________________
Birth & Developmental hx:
_______________________
Nutrition (for pedia):
___________________________

History of Present Illness:

Location:___________________________________
__
Onset:
_______________________________________
Character:
____________________________________
Intensity:
_____________________________________
Duration:
____________________________________
Aggravation:
__________________________________
Alleviation:
___________________________________
Associated Symptoms:
__________________________
____________________________________________
_
NURSING ASSESSMENT II (guides in asking the patient)
1. Activities-Rest
a. Activities
Child:-Is he studying/goes to school?
-Is he playing with other
children?
Adult:-status of employment?
-Is he working? Whats his
occupation?
-Where does he usually spend
most of his time if not working?
b. Rest
What time does he usually sleep at
night?
What time does he usually wakes up?
c. Sleeping Pattern
When does he usually sleep? In night,
day, noon.
2. NutritionalMetabolic
a. Typical intake
(food,fluid)

How many times does the pt. usually

eat a day?
What food does he usually eat a lot?
Does he love eating street foods and
junk foods?
How many a glass of water does him
usually drink a day?

b. Diet

Does he eat whatever food is served

especially fatty or fatty acids?
What is his usual diet?

c. Diet Restrictions

Is there any diet restrictions? if there

is, what?

d. Weight
e. Medications/
supplements food

Get the pt. weight as much as possible.

Does the patient take any vitamins or
supplements?

3. Elimination
a. Urine (frequency,
color,
consistency)
b. Bowel (frequency,
color,
consistency)
4. Ego Integrity
a. Perception of Self

b. Coping
Mechanism

5. Neuro-sensory
a. Mental state

b. Conditions of 5
senses (sight,
hearing, smell,
taste, and touch)
6. Oxygenation
a. Vital Signs
b. Lung sounds

c. Hx of Respiratory
Problems
7. Pain-Comfort
a. Pain (location,
onset, character,
intensity,
associated
symptoms,
aggravation)
b. Comfort
measures/alleviati
on
c. Medications

How many times does the patient

usually urinates a day? Its color
and odor?
How many times does the patient
usually defecates a day? Its color
and odor?
Child:-Does the pt. usually spend most
of his time in playing than in studying?
-Does he complete chores at
home?
-Does he do whatever he
wishes?
Adult:-How does the patient perceived
his self? Ex. A strong person
Who usually helped him to cope up
with the stressors or patterns in
his life?
Whom the patient considers as his
support system?
Is the pt. mentally healthy?(as
evidenced by going to school & etc.)
Are there any problems about his 5
senses?
Does the patients 5 senses are
functioning well?
(Before hospitalization: not taken)
What does the patient or the SO
observed about his lung sounds, ex.
When pt. is tired?
Is there any history of respiratory
problems?
Use a pain scale and be specific on
what part of the body, ex. Pain scale of
6/10 on the joint (upper extremities)

How does he alleviate pain?

What medications does he usually

take?(to alleviate pain)

8. Hygiene & activities

of daily living

9. Sexuality
a. FEMALE:
(menarche,
menstrual cycle,
civil status, no.
children,
reproductive
status)
b. MALE:
(circumcision, civil
status, no. of
children)

Does the patient take a bath regularly?

How many times does the patient take
a bath a day?
Does he usually reuse his used cloth?
Does he exercise regularly?

At what age did her menarche

occurred?
Her civil status?
How many children she had if married?

Is he already circumcised?
If not, is he willing to undergo a
circumcision?
How many children he had if married?