SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
OB/Gyne Assessment Tool

Preliminary Information:
Patient’s Initial:________________________ Age: ___ Sex Male Female Civil Status _______ Occupation______________
Informant: ___________________________ Relationship of Informant to patient: _______________ Religion ____________________
Date of examination: ___________________ Area of assignment____________________ Day of hospitalization __________________
Allergies: Food: _____________________ Drugs: ___________________ others: ________________________________
VS : T_______ BP____ / _____P______ RR_______ O2 Sat______ Weight: _________ Height ___________
PAIN and DISCOMFORT Diagnosis:__________________________________________ CARE CONCERNS
Presence of Pain/discomfort: None Yes Pain
Intensity score: ___Location:___________ Radiation:____________ Duration: _______ Onset :_________ Altered Comfort
Quality: cramping dull burning sharp shooting throbbing others:_______________ Activity Intolerance
Aggravated by: movement light pressure others:____________________________________ Ineffective Coping
Relieved by: eating quiet environment cold heat rest others_______________________ Others:________
Medication/s: _____________________ Non-pharmacologic mngmt: __________________________
Objective data: grimacing guarding affected area crying withdrawal others:_________________
Effect of pain to sleep_______ emotions _________ appetite___________ activity ______________
Effects of pain: nausea/vomiting Others __________________________________________________
HEENT Diagnosis:_________________________________________________________ CARE CONCERNS
HEAD: asymmetrical unable to support head midline & erect facial color: _______ pain/discomfort Sensory/Perceptual
HAIR/SCALP: alopecia baldness infestations abnormality:__________________________ Alteration
EYES: nystagmus strabismus Lens Opaque Clear __ L __R Color of sclera:______ edema Body image
acuity problems:___________ uses corrective lens:__________ others:_______________________ disturbance
EARS: discharges:_____ pain:_____ swelling:_______ tinnitus hearing problems: __L __R Impaired Swallowing
NOSE: nasal discharge epistaxis occlusion sinus tenderness:_______ others _________________ Risk For Injury
MOUTH: Lips: intact cracked lip color______ others:_____________________________ Risk For Aspiration
Mucus membrane: moist dry sores lesions _________ bleeding others______________ Others:________
Dental: decays ________ uses dentures chewing problem gingivitis others_______________
Tonsils: pain swelling : size ______ swallowing difficulties others_____________________
NECK:/THROAT: hoarseness speech difficulty lump lymph node tenderness:_____________
thyroid enlargement: grade:_____ torticollis lymph node enlargement______________________
attached appliances/ devices(IJC,Trach) status:_____________________________________________
Others ________________________________________________________________________________
Medication/s ___________________________________________________________________________
Dx result ______________________________________________________________________________
NEURO Diagnosis:_______________________________________________________________ CARE CONCERNS
LOC: oriented disoriented unresponsive Seizures
GCS score: M___ V___ E___ Total=___ Sensory state Delirium
Speech: normal dysphasia slurred blocking poverty of speech Aspiration
selective mutism aphasia ( Expressive Receptive Global) Language
Cognition: Orientation: time place person self Depression
Memory: immediate recent remote Decreased ADLs
Pupils: size: ______ reaction: _______________ deviation: _____________________ Sensory
Cranial nerves: abn findings_______________________________________________ thought process
Swallowing: normal dysphagia others ___________________________ Others:_________
Behaviors: calm restless agitated withdrawn others:________________ __tactile
Seizures: No Yes Type: ____________ Duration: ____ Incontinence ______ discrimination
SCI:level of injury:___ complete incomplete sensory: light touch __ pin prick___ __2 pt
anal sensation ___ bladder sensation ___ Motor: diapraghm ___ abdominal ____ discrimination
anal control__ bladder control ___ Elbow: flexors___ extensors ___ __stereognosis
fingers: flexors __ abductors__ ; hip flexors ___ ; knee extensors ___ ; __graphesthesia
ankle: dorsiflexors ___ plantarflexors __ ; long toe extensors ___
Others: +brudzinski +kernigs headache:________ vertigo syncope
Others ________________________________________________________________
Medication/s ___________________________________________________________
Dx result ______________________________________________________________

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MUSCULO-SKELETAL Diagnosis:______________________________________________ CARE CONCERNS
Falls
Mobility: hemiplegia ____ quadriplegia paraplegia ____ paresis _______ Motor strength
Decreased ADLs
Muscles: spastic flaccid tremors tics spasms pain_____________ &DTR
Sensory deficit
Muscle mass: adequate emaciated atrophy _________ others ____________
Disuse Syndrome:
Assistance Needed: none partial full assistive device: __________________
Sp:________________
Joints: ROM: full limited:_________ redness :_________ edema:__________
Impaired Physical
stiffness:________ arthritis tophi:________ deformities _______________
Mobility
Amputations:_________________ contractures:_____________ foot drop
Impaired Bed
Coordination: impaired __________ slowed Gait: _________________________
Mobility
Posturing: kyphosis lordosis scoliosis decorticate decerebrate
Others:_________
opisthotonus others:__________________________________________ Hand Grip:
Functional disability: feeding toileting transfer dressing others_____________ L: ______
Supports: cast:_________ sling:________ traction:_______________________ R:______
Others __________________________________________________________________ Foot pushes:
Medication/s ______________________________________________________________ L:_______
Dx result _________________________________________________________________ R:_______

RESPIRATORY Diagnosis:_______________________________________________________ CARE CONCERNS

Anterior:Posterior: Airway Clearance
Chest shape: ____________ deformities _____________ pain/discomfort
Gas exchange
Rhythm : regular irregular (sp)_________________________________
Actual/potential
Depth : normal shallow deep mouthbreathing
Infection
Quality : normal labored stridor egophony
Tissue
Expansion: symmetrical asymmetrical paradoxical
Perfusion
flaring retractions: _________ accessory muscles: ____________
Lung sounds:
Dyspnea: absent at Rest with Activity SOB orthopnea
A-Absent Others:__________
Cyanosis : absent central peripheral
C-Clear (Normal)
Cough : absent dry harsh productive non-productive hemoptysis
D- Decreased
Secretions color/amt: ______________ night sweats
W- Wheeze
Fremitus: present absent
Cf - Crackles (fine)
Chest Tubes(loc/charac/status):_____________________________________
Cc –Crackles (coarse)
Oxygen therapy: via________ LPM _______
Lung percussion:
MechVentilator : type:_______ setting: ____________ mode: ___________
R-resonant
Artificial airway: ET NT TT others____________________________
H-hyper resonant
Medication/s _____________________________________________________
F-flat
DX Result: ______________________________________________________
Dl -dull

CARDIOVASCULAR Diagnosis:___________________________________________________ CARE CONCERNS

Activity intolerance
chest pain palpitations nails: color_________ clubbing capillary refill:_____ seconds
Impaired comfort
Apical pulse: rate: ____ regular irregular Pulse Deficit: No Yes PMI:_______________
Cardiac
Abnormalities: murmurs:______ thrills:______ bruit:________ heaves: ____________________
Output
dynamic precordium pericardial friction others _____________ JVD:Meas.________________
Tissue
Auscultatory areas: Aortic:____ Pulmonic: _____ Tricuspid: ______ Mitral:______ S1 S2
Perfusion
Cardiac Monitor: yes no Pace maker: no yes Rhythm : regular irregular:_____________
Skin Integrity
Pulses : Radial ____L____R Femoral ____L____R Pedal ____L____R
Others: ________
Edema: pedal L/R ankle L/R lower leg L/R face non-pitting pitting Grade: ______________
Type of IV line: central loc. ________ peripheral loc. _________ IV infiltration char:_____________
CVP leakage CVP level:____ varicosities __________ fistula/shunts: loc _________________
Hema: bruising:___petechiae ___ ecchymosis ___purpura ___ hematoma
BT Type of BT: ________________ :#of units_______ reactions:____________________________
CBG: _____ q ______ insulin type: ____________ units: ___________
Others:________________________________________________________________________________
Medication/s :___________________________________________________________________________
Dx results: _____________________________________________________________________________

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GIT and GUT Diagnosis:_____________________________________________________________ CARE CONCERNS
Nutrition
Diet: oral type: ____________________preference: ______________ NPO (SINCE):______________
Aspiration
Breakfast ( 100% 75% 50% 25% 0%) others: ____________________________
Swallowing
Lunch: ( 100% 75% 50% 25% 0%) others: ______________________________
Fluid
Dinner: ( 100% 75% 50% 25% 0%) others: ______________________________
Constipation
BMI: _________ TPN: PPN type: ______________ rate: ___________ tolerated: ( yes no)
Diarrhea
Enteral tube type: NGT gastrostomy jejunostomy others: ___________________________
Bowel Elimination
Insertion date: _________ NG tube suction: low gravity
urinary elimination
heartburn anorexia nausea emesis (describe): ________________________________________
gastrointestinal motility
Bowel Sounds: normoactive hypoactive hyperactive absent
Skin Integrity
Abdomen: soft tender firm distended rigid tympanic
Others___________
dull ascites fluid waves bruit @________
Abd’l girth: ____ waist C: ___ hip C: ___ w/h ratio______ BMI:_________________
Bowel Activity: normal regularity : __________ Last BM:___________
Feces: color________ amount/size:___________ characteristics:________________________________
diarrhea constipated (# of Days) _____ Aids to BM:__________________________________
melena hemorrhoids others_____________________________________________________
Liver: tenderness enlargement esophageal varices others:____________________________
Kidneys: flank pain BUN_______________Crea: _________________
Voiding: continent incontinent frequency urgency hesitancy burning nocturia
dysuria anuria hematuria others:_________________________________________
Urine: characteristics: _______________________output: (7 3): _____311: _____11 7: ______________
Mass: (Location): _______________ characteristics: __________________________________________
Dialysis: hemodialysis:__________ peritoneal:________ Fluid restriction: ______ml/day
Catheter: Foley Suprapubic Condom Peritoneal A/V Fistula
Bowel Diversion: (charact/site): ___________________________________________________________
Urinary diversion: (charact/site): __________________________________________________________
CBI: type of solution _____________________ drainage: ___________________________________
Medications:__________________________________________________________________________
Screening Methods: colonoscopy sigmoidoscopy barium Enema barium sw. FOBT
Last Date Performed: ________ Results: ____________________________________________________
Lab results: S/E:______________ UA: _______________ AST/ALT________ Albumin_________
Other Dx result:_________________________________________________________________________
Surgeries: ____________________________________________________________________________
Medications:___________________________________________________________________________
REPRODUCTIVE SYSTEM Diagnosis__________________________________________________ CARE CONCERNS
Menses: Regular Irregular; Amenorrhea: primary Breast (draw abnormalities here) Sexual Patterns
2ndary Menopausal dysmenorrhea Heavy Knowledge Deficit
Flow Others___________
# of pads used during menstruation: __________
Characteristics of menses/discharge: __________________
Breast: symmetry:_____ discoloration tenderness
dimpling: _________ nodules:__________
nipple discharge__________________________
surgically absent__________________________
External Genitalia: Excoriations Rash Lesions Vesicles Inflammation itching
Discharge Charac.:__________________________________________________________________
Bleeding (specify cause)__________________________ infertility tumor/cyst
STIs ______________________________________________________________________________
Past surgeries:________________________________________________________________________
Screening Methods: BSE CBE Mammography others:_________________________
Pap Smear (last pap smear) _________________ Results: ___________________________________
Family Planning Use: No Yes Natural:_______ Artificial: _______ Since when ____________
Medications: __________________________________________________________________________
DX results____________________________________________________________________________
Surgeries: ____________________________________________________________________________

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PRENATAL ASSESSMENT: Diagnosis:________________________________________________ Nutrition
Last Prenatal Visit ___________ Frequency Of Prenatal Visit:________ Body image
Height_______ Weight________ BP ________ PR_______ RR_____ T_______ Elimination
GP______ TPALM______ LNMP__________ EDC/EDB ______ Fundic Ht:_________ Circulation
Tetanus Toxoid: (When?) T1 _____ T2_____ T3_____ T4_____ T5_____ Sexuality
CBC___________________________ Urinalysis____________________________ Others: ___________
Blood Type _____ Other Screening Test:_______________________________________
Ultrasound: When?____________ Results_______________________________________
Leopold’s Maneuver results: Attitude_____________ Lie ____________ Position___________
Presentation______________ Engagement______________
FHT _______ Medications ______________________________________________________
Pain
INTRAPARTAL ASSESSMENT: Diagnosis _________________________________________________ Altered comfort
GP (TPAL) ________________ LMP _______________ AOG _______________ Activity intolerance
Labor: Duration_________ Frequency_________ Interval_________ Intensity_________ ineffective coping
BOW ruptured: Time__________ [ ] spontaneously [ ] artificially color/char. _________ Body image
Date of delivery __________ Place of delivery [ ] NID [ ] Lying-in clinic [ ] Hospital Others: __________
Method of delivery [ ] NSD/SVD [ ] CS [ ] Forceps
Time of delivery __________ Gender of baby [ ] male [ ] female condition [ ] alive [ ] FDU
Time of delivery of placenta __________ presentation __________ [ ] complete [ ] incomplete
[ ] Episiotomy [ ] Laceration Amount of blood loss __________
Medications: __________________________________________________________________________
DX results____________________________________________________________________________
Breastfeeding
POST PARTUM ASSESSMENT: Diagnosis ________________________________________________ Bleeding
BP _________ PR __________ RR __________ Temp __________ Circulation
Breast/nipples: Engorged Cracked Inverted Others:_______________________ Infection
Episiotomy: Redness Edema Ecchymosis Discharges______ Elimination
Approximation_____________ Pain ______ Parenting
Lochia: Color________ No. Of Pads Used______ Others________________________ Other: __________
Uterus: Consistency _________________ Height_____________
Elimination: Bladder: Urine Output ______ Distention others_____________________
Constipation__________ Hemorrhoids-___________ Others_________________
Homan’ S Sign chills Others: _________________________________________________
Emotional Response/state: [ ] taking-in [ ] taking hold [ ] letting go
[ ] Post partum depression [ ] psychosis
Rest And Sleep___________________________ Others_______________________________
Meds:________________________________________________________________________
INTEGUMENTARY SYSTEM Diagnosis______________________________________________ CARE CONCERNS
skin integrity
Temperature ______Turgor: good poorSx______________
thermoregulatory
Characteristics: dry moist oily diaphoresis
status
Color: pale cyanotic flushed jaundiced mottled
Risk for infection
Lesions(type):__________loc/charac._______________________
Others:_________
wounds(type)__________loc/charc_________________________
Ulcers (type)____________ loc/char________________________
infestations ___________________________________________
Others: _________________________________________________
Burns: %______ degree: ________ implants_______________
Medication/s______________________________________________
DX results_______________________________________________________________________
PSYCHOSOCIAL Diagnosis_____________________________________________
CARE CONCERNS
ASSESSMENT
body image
Self-Perception/Self-Concept, body image___________________________________________________
self esteem
Aids and augmentations: ________________________________________________________________
thought alteration
Development: stage, tasks and concerns:(Erickson)____________________________________________
perceptual
Expectations and concerns about hospitalization: ____________________________________________
alteration
Effects of hospitalization/illness to self:_____________________ work: ________________________
Fear
family: _______________________________ social life:___________________________________
Anxiety
Learning needs:________________________________________________________________________

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Mood: depressed expansive irritable euphoric mood swings others________________ Powerlessness
Affect: apathy flat blunted restricted labile others ______________________________ Hopelessness
Thought: content _________________ process _________________ flow___________________ Sleep pattern
Perception: delusion_________ hallucination __________ illusion ___________________________ disturbance
others ______________________________________________________________________________ Ineffective coping
Motor: hypoactive hyperactive others__________________________________________________ Impaired
OTHERS: anxiety______________________ ambivalence___________________________________ adjustment
Behavior: Appropriate to situation? Yes No, describe:_______________________________________ Family needs
Sleep: difficulty falling asleep not rested after sleep aids to sleep: ___________________________ Parenting needs
Meds_________________________________________________________________________________ Spiritual needs
Communication pattern: non- verbal verbal. Spec__________________________________________ Cultural needs
Stress-Coping pattern? Sources of stress: __________________________________________________ Suicide risk
Ways of coping: ________________________________________________________________________ Role conflict
Availability of support? : source:____________________ adequacy: ______________________________ Sadness
Role-relationship pattern: (describe role, interaction pattern and concerns) Depression
a. Family: Others:_________
_____________________________________________________________________________________
b. Work :
_____________________________________________________________________________________
c. Community:
_____________________________________________________________________________________
Sexuality and sexual concerns? Sex Preference:_________ Sexual problems: ____________________
Aids to sex performance:____________________________ others____________________________
Social history : lives alone lives with:
_____________________________________________________________________________________
Lifestyle risk: Smoking, pack years ________ tobacco use: chew ___ smoke ____
Alcohol use; amount:_________how long?__________
betel nut chewing: length of use:______ social drug Type? ____________ Frequency? ___________
Financial
concerns(describe)______________________________________________________________________
Housing concerns: _____________________________________________________________________
Legal concerns:
_____________________________________________________________________________________
Cultural/religious practice important to client during
hospitalization?_________________________________________________________________________
Any advance directives? yes, specify: _____________________ No Need for more information
Other concerns:
______________________________________________________________________________________

I do hereby certify that all information written on this assessment tool are true and correct.

Name of the Student _______________________________ Signature _____________________ Date ____________

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