SAINT LOUIS UNIVERSITY SCHOOL OF NURSING ‘Adult Assessment Tool Preliminary information: Patient's Name: ‘Age:__ Sex Male Female Civil Status __Oceupation___ Informant: Relaionship of informant to patient: Religion Date of examination: ‘Area of rotation ‘Day of hospitalization Alegles Food Drugs: Doters: VS: 1. BP__?__P__RR 28a ‘Weight: Height PAIN and DISCOMFORT | Nog Diagnosis: CARE CONCERNS ‘Presence of Painidiscomfort CINone ClYes OPain Intensty sore: _Loeation,___—Radiation,__Duration: _Onset:__ | tered Comfort ‘Quality: C eramping Cidal SburingSsharp shooting Diirobtirg Cl others activity Intolerance Aggravated by: Ci movement Ciight pressure Dother: inetiecive Coping Relieved by: Cleating Claust environment cold Cheat C1 rest Clothers. Dothers:__ (DMedications: _____—__D) Non-pharmacological mgt Objective data: Cgrmacing Cguarding affected area Crying O withcrawalClothers: Effect of pain eClseap___Clemotions _Clappetite Claciivity Effects of pin: CI nausealvomting™] Others HEENT | Neg Diagnosis (GARE CONCERNS EAD: To support feed midine & erect facial color PI painiiscomfot | OSensoq/Percentval HAIRISCALP: Clalopecia Cltskiness infestations Oi abnormality Altertion EYES: Cinystagmus Cistrabismus Lens (Opaque Clear_L_R Color of sclera:___Cledema | C).Body image acuity problems:__ uses corrective lens: others disturbance EARS: Cischarges.___Cipsin:_ swelling: __Oltnnitus hearing problems: _L_R | CI impaired Swalowing NOSE: Casal discharge Clepistaxs Cloccusion Clsinus tenderness. others ‘ORisk For inary MOUTH: Lips: intact Cleracked Chip cot Dothers isk For Aspiration Mucus membrane: moist dry sores Clesions bleeding others__ DOthers:_ Dental: Cdecays: ‘Dluses dentures Clcnewing problem Ogingwvits Cothers___ Tonsis: pain Clsweling size ___ swallowing citficules (others NECK/THROAT: Chhoarseness CIspeech dificuty Cllump lymph node tenderess:_— Citnyroid enlargement: grade-__ Ditorticolis. 01 lymph node enlargemment_____ attached appliances! devices(UC, Trach) status: Others: Medications Dic result NEURO _| Nog Diagnosis: ‘CARE CONCERNS LOG: Clorented Cl disoriented Cl unresponsive ‘Sensory siate | Ci Seizures GCS score: M__V__E_ Total=-_ a © Detiium Speech: 1 normal Cdysphasia Olsiurred Oiblocking Dlpoverty of speech O DaAspiration Clselective mutism Claphasia (O Expressive Oi Receptive ) Global) O Language Cognition: Orientation: Cl ime Clplace Glperson Ci self D Depression Memory:Climmediata Clrecent C remote Decreased ADLS Pupils: sze:__ reaction: ___devation: Di Sensory Cranial nerves: abn findings thought process Swallowing. Clnommal Ci dysphagia others _ ttle Dothers___ Behaviors:Chaim Direstess Clagitated C1 withdrawn Clothers: ‘scrminaton ‘Selzures: No Ces Type: Duration: ay ee Grertge Cyrcope discrimination Others ‘ tc =a Dic resuit “ Gopyright©2012SLUSON adult Page 1‘GIT and GUT | Nsq Diagnosis: CARE CONCERNS Det Coraltype;___—— preferences: CONPO(SINCEY_ Nuon Breakiast (100% CVX 50% CB5% CO%) others: eo ce Lunch: (100% CO7S% 50% C25% COX) oes: eae aS Diner (100% 75% O50% C25% Cd%)oibers: BM; OTP type: rate:______tolerated: (Clyes Ono) eSaiat Enteral tube typeINGT Cigastrosiomy — Clejunostomy others: C1Bowel Elimination Insertion date: NG tube suction: low gravity Caan etininaon heartburn anorexia Chausea Cemesis (describe): Seidl Bowel Sounds: Chnormoactve Chypoactive Chhyperectve Clabsent ae Abdomen: Colt Ctender Clfirn Cdisiended Crgid Chtyrnpanic ae Dull Dasctes Dtuid waves. Obit @. wh ratio_ EM, oe Liver Chendemess Clanlargement Oesophageal varices others: Voiding: Econtinent Cncontinent Cirequency Curgency Chestancy Curing ene 47. Chentoneal: (DF luid rectrefon: ___mlay Catheter Foley CSuprapubie Goede CPettoneal CLAN Fis Screring Mabon) sigmoidoscopy CZ barium Enema) barium sw. COFOBT uk ____ PASIAN. CAbumin, ‘Medications: REPRODUCTIVE SYSTEM | Nog Disoneas. ‘CARE CONCERNS Ti Sexual Patterns CRegularMenses Cliregular CPrimary Amenonhea CiSecondary Amenomhes a Dana Menopausal Heary Flow GDysmenorhea # of pads used during menstruation: noma Characteristics of menses/tischarge: Ris Breast: symmetry: Diiscoloration:_ Ditenderness, ‘Bidimpling: ‘(Chodules:___C nipple discharge___Ci surgically absent______ Extemal Genitalia: CEExcoriatons CResh Olesions Civesicies Cintarmmation Discharge Chara. Screening Methods:CIBSE —C1CBE Mammography. others (CPap Smear (last pap smear) Results: Scrotum charac. ___Testioular charac. # of Testes._) descended O] undescended Displaced Meatus (Hypospadia/Epispadia) Erectile Dysfunction: Oyes Cho D priapism Penile Discharge: Characteristes: CHernie: _umblical _ inguinal CPhimosis CBalantis Olhydrocele Cvaricocale Cothers Screening Methods: CTTSE GORE CPSA others Famiy Planning Use:ONatue__ rif: Medications: OX results Sa TESA NE Copiyright©2012SLUSON Adult Page 3‘Surgeries: a INTEGUMENTARY SYSTEM | \NsgDignoss | GARE CONCERNS: Temperature Turgor:Digood Qpoor Sx Housing concerns: Legal concerns: Other concerns: ‘Sexuality and sexual concems? SexPreference,_____CiSexual problems: Aids to sex performance: ee Ree Social history Clives alone Cllives wih Lifestyle risk: CiSmoking, pack years (Cetel nut chewing: length of user Cisotial drug Type? __ Frequency? Financlal concems(deseribe) (Culturalireligious practice Important to client during hospitalization? Any advance directives? Cyes, specity: r (No CNeed for more information Characteristics: ily Limoist Doty Disiaphovesis oe Colorpale Ceyarotic CHushed Claundced Cineted te as: Chesions(type). foc, others Dheoundstype) Tocchare DUcers Toolbar. Diinfestatons Duns, degree ry impiants, Medication’ DX resus 08 PSYCHOSOCIAL ASSESSMENT _ | Neq Diagnosis CARE CONCERNS Selh-Perception/Set-Concept, body image. pepe Ji aed spinon | tought aration asachaticrw are] ceases wisi eal alii Speen eae Effects of hospitalizationiliness to Ose nor Croor Cham social ite Paes Learning needs: Se Mood: Cepressed Dlagensive Cimiable Cleuphorie Cinood swings Ca others eyeenen: ‘Affect apathy Oat Chiunted Crestricted able D others aera ‘Thought: C1 content Cprocess Ditiow. ae Perception Hetusion ‘hallucination Gilson others eee re Motor-Cl hypoactive [hyperactive Cothers OTHERS emiety ambivalences | Cimeaired adjusonent Behavior: Aporoprate to situation?CIves CN, describe Ee ae feos ‘Sloop: Cktitiouty fang asleep Cot rested after sloep aids to sleopr Teds. oan tino Communication paler Inor-verbal rbal Spec. | Stress-Coping pattern? Sources of sess: ways of coping Lee eas ‘Avallabilty of support? : eouree, ‘adequacy eae Role-relationship pattern: (describe roa, interaction patter and cancers) Feat a.Famiy ree eee GiDepressin Community. ‘OOthers:___ CO Acohol use: amount;_____how long? | do hereby certty that al information written on this assessment fool are true and correct Name of the Student Signature Date Copyright®2012SLUSON Adult Page +MUSCULO-SKELETAL | Neg Diagnosis: ‘GARE CONCERNS a : ; Fels Mobility: hemiplegia -O) quadriplegia OI paraplegia Clparesis__ Metrstomets | 0 ‘Als Muscles: Ospastic 0 flaccid D tremors] tics CO spasms Cpain_ a Muscle mass: CI adequate Cl emaciated CO etophy others G lelane ‘Assistance Needed: Clnone 0 partial Ditull assistive device ee Sarees Joints: ROW: Chul Climited____ redness Decema: ____ Cetifness: Darth Ehophi: Tidetormites Espa chica Clampatatins: Clcontrecures: ist drop a Coordination impaired slowed Dispaeiex: Posturing: Ckyphosis Clerdosis scoliosis Ci decortcate Cidecerebrate May: Cloplsthotonus others, 5 Others,__ Functional disability: Cieeding Ciaiatng Clrencter Cerwevicg others Supports: Ccast___ sing: Civacton: Others Mescatonls cools LR DUDE Pesce a a eae Nes | eS RESPIRATORY | Nsg Diagnosis. CARE CONCERNS: Golan Tislomiies____D palntisconvon | Ateror: Pstear; | ClAiway Cecrance Rhythm ‘Clrequiar Clireguiar (sp)__» Bese Depin: Cnormal C3 shallow C2 deep moutireathing Eee Qualty ‘Ghermal labored Qstrider Clegonhony lnfecton Expansion: Clsymmetricel Clasymmetrical Jparadoxical Oesue (Ditaring Diretractns:___Clacsessory muscles: Lang soands: Faas ‘Dyspnea:ClabsontClat Rest Clits Aetivty CISOBCI orthopnea ne (Cyanosis: Dabsenteeniral peripheral Nae ae eo ‘Cough Clabsent] dey] harshLIproductive I non-productive Clhemoptysis | D- Decreased Usecretions coloriamt Sight sweats Wes Whosce, Fremitus: Clpresent absent Sema ee) ‘Chest Tubes(ocicharacistatus) Co--Croile (ocore) cea a ra Lung percussion: Mech Ventilator: type: seting mode: toes! Artic siwey OETONT OTT others oe CARE CONCERNS: Tia intlerence ee Dicardac ' Output ‘Ausoultatory areas: Aortic Pulmonic__Tricuspi:___——sMia_—=—sO S182 Corssue Cardiac Monitor yes no Pace meker: ino Qlyes Rhythm :D regular © irregular, Pestaton Pulses: Radat___R Femorat__L__R Pedal__L__R ee Edema: pedal UR Glankio UR Dlowerlee UR Diece Gronsiting Opting Grace: =| Compliance to Type oflV fine: Cleentral oc. _____ peripheral foo._____ CV inition char: aerener roa DlovP leakage CVPleve:__ Clvertcosies Cifstulalshunts: Joc Dlothers: —__ Hema: Cbnising:__pelechiae __ecchyriosle purpura __ hematoma CBT Typeot BT: ___ fot unts____ EB reaxtions: CBG: insulin type: ns: Othess: Medications Drcresuts: Pn caesar el Copyright©2012SLUSON Adult Page 2