BUKI DN ON ST ATE UN IVE RS ITY

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: _________________________________________________________
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II. NURSING ASSESSMENT
A. DIGESTIVE/METABOLIC/NUTRITION

Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.
Objective

Subjective

General Appearance: □ Alert/responsive
□ Apathetic □ Cachexia □ Abdominal Distention
□ Mass □ Tenderness/pain
Skin: □Dry □Warm □Cold □Moist □Edema
Turgor: ____________________________________

Usual Diet: ___________________________________
No. of meals per day: ___________ (3x a day)
No. of fluid drink each day: _______(8-12 glasses/day)

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
□ Obese
□ Thin

□ Endomorph

□ Alcohol and Beverages ________________________
Undesired Weight loss:
Undesired Weight gain:

□ Yes
□ Yes

□ No
□ No

Food restrictions R/T intolerance and health
problems or religious practices?
_____________________________________________
_____________________________________________
Difficulty in eating and swallowing:
_____________________________________________
_____________________________________________
Previous/Recent Illness:
□ Diabetic □ Hyperthyroidism □ Hypothyroidism
□ Colon Cancer □ Abdominal Pain
Comment: ___________________________________
_____________________________________________
_____________________________________________
Elimination pattern: □ Diarrhea □ Constipation
Frequency of BM:______________/day

Loss of Appetite: □ Anorexia □ Bulimia
Body weight: _____________kg
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Nursing Diagnosis:
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective
Subjective
Breath 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/min
Rate: ________________________
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: __________
□ No
Comment:____________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
_________________________________________________________________________________________
_
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_________________________________________________________________________________________
_

C. CARDIOVASCULAR/CIRCULATORY SYSTEM

Note:

Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective
Subjective

Temperature: _______________ Celsius
Blood Pressure: Right_______ Left ___________
Pulses:
Carotid Pulse: □ Thready □ Weak □ Strong □ Absent
Rate: Right______Left______
Apical: □ Regular

□ Irregular

Rate: ____

Radial Pulse: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right______ Left _______
Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right_____ Left _____
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak □
Strong □ Absent Rate: Right_____ Left _____

Heart Rhythm: □ Tachycardia
□ Arrhythmia/ Dysrhythmia

□ Bradycardia

Jugular Veins Distention:
□ Positive □ Negative
Nail bed Color : □ Pink

□ Blue

□ Pale

Capillary Refill: ________ (Normal less than 2 sec)
Edema: □ Pitting □ Non Pitting
Location: _____________________________
Varicosities: □ Yes
□ No
Location: __________________________________
Calf Tenderness (Homan’s Sign):
Right
□ Positive □ Negative
Left
□ Positive □ Negative

Previous/Recent Illness:
□ CVA
□ CHF
□ MI
□ Thrombophlebitis
□ Family History of HPN □ Renal Failure
□ Bleeding Disorder __________________________
Comment: ____________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Do you experience any of the following:
□ Chest pain
□ Arm pain
□ Leg pain
□ Joint and Back
□ Dyspnea
□ Orthopnea
□ Cough
□ Numbness and Tingling
□ Light headedness □ Fatigue and weakness
□ Palpitations
Comment: ___________________________________
_____________________________________________
_____________________________________________
Exercises:
Type: _______________________________________
Frequency: __________________________________
Duration: ____________________________________
Problem experience with usual activity and exercise:
Comment: ____________________________________
_____________________________________________
Factors Affecting Activity Intolerance:
Comment: ____________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective
Subjective
Skin: □ Dry □ Intact □ Warm □ Cold □ moist
Turgor:_____________________________________
□ Pallor □ Cyanosis □ Jaundice □ Rashes
□ Acanthosis Nigricans □ Albinism □ Erythema
□ Edema □ Petechia □ Itching
□ Drainage
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer
Temperature: _________
Hair: □ Alopecia □ Hirsutism □ Patchy hair loss
Distribution: ________________________________
Nails: □ Dirty □ Pallor
□ Cyanosis
□ Clubbing
□ Paronychia □ Onycholysis
Capillary refill: __________ (Normal less than 2 sec)
Color: _________________

Comment : ___________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Comment:____________________________________
_____________________________________________
_____________________________________________
Comment:____________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_

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E. ELIMINATION
Objective
Mobility and Dexterity:
□ Ambulatory □ Non-ambulatory
□ Bedridden □ with assistive device
Tubes/Drainage/Stoma:
□ Colostomy □ Ileostomy
□ NGT
□ Catheter
□ Suprapubic Catheter
Abdomen:
□ Soft
□ Firm
□ Distended □ Non-distended
Bowel Sounds: (5 – 20 sounds/min)
□ Normoactive
□ Hypoactive
□ Hyperactive(Borborygmi) □ Absent
Measurement:
Intake ____________ Output:_______________
Edema:
□ Yes
□ No
Location: __________________________________
Present Urine Color: ________________________
Note: Assess urine frequency, color, odor control,
comfort/gyn-bleeding, discharge.
Comment: __________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

Subjective
Previous/Recent Surgery/Illness:
_____________________________________________
History of pain and discomfort: _________________
_____________________________________________
Diet: ________________________________________
Personal Elimination Habits:____________________
_____________________________________________
Elimination Problem:
□ Loose bowel movement _________
□ Constipation □ Impaction □ Fecal Incontinence
□ Neurologic Impairment □ Dysuria □ Urgency
□ Polyuria □ Oliguria □ Nocturia □ Dribbling
□ Incontinence □ Hematuria □ Retention
□ Discharge
□ Residual urine (> 100ml)
Comment: ___________________________________
_____________________________________________
Medication taken:
□ Analgesic Narcotic
□ Antibiotics □ Anticholinergic □ NSAID
□ Aspirin
□ H2 antagonist
Fluid intake per day: __________ liters/day
Physical Activity: _____________________________
Comment: ___________________________________
_____________________________________________
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___________________________________________ Excessive Perspiration and Odor Problem:
___________________________________________ □ Yes □ No
Consistency:
Stools: ______________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__
F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.
Objective
Subjective
Mobility: □ Ambulatory □ Non Ambulatory
□ Bedridden
□ Appliance __________________________
Gait and Posture: □ Lordosis □ Kyphosis
□ Scoliosis
□ Shaftling □ Poliomyelitis
□ Amputated Limb ______________________

Do you experience any of the following:
□ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Joint pain
Comment ____________________________________
_____________________________________________
_____________________________________________

Club foot (Talipes)
□ Varus □ Valgus □ Equinovarus □ Calcanous

Comment: ___________________________________
_____________________________________________

□ Use of Appliance __________________________ Comment: ___________________________________
Muscle Tone/Strength:
□ Normal □ Slight weakness
□ Average weakness
□ Poor ROM
□ Severe Weakness
□ Paralysis
□ Atrophy
□ Hyperatrophy
□ Spasm

_____________________________________________
Comment: ___________________________________
____________________________________________
_____________________________________________
_____________________________________________

Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
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□ Contractures/Deformities □ Crepitus
□ Tingling/Numbness (Carpal Tunnel Syndrome)
□ Ankylosis □ Foot Drop □ Pressure Ulcers
□ Urinary Elimination changes _________________

Comment: ___________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Calf Tenderness (Homan’s Sign):
Right
□ Positive □ Negative
Left
□ Positive □ Negative

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_
_________________________________________________________________________________________
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_________________________________________________________________________________________
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G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,
Objective
Subjective
LOC: □ Alert □ Lethargic □ Comatose
□ Unresponsive □ Obtunded □ Stupor
□ Decorticate □ Decerebrate
GCS Score: _________
Cushing Triad (Respiratory changes, Increase BP,
Decreasing level of Consciousness)
□ Positive
□ Negative
Sensation: □ Positive

□ Negative

Pupillary Size: □ PERRLA □ Anisocoric
Orientation: □ Person

□ Place

□Time/Date

Check the Following Risk Factors:
□ Older Adulthood □ Male
□ Hx Stroke or TIA
□ Hypertension
□ Smoking □ Hx CVD
□ Sleep Apnea
□ High level of Cholesterol
□ Drug Abused
□ DM
□ Oral Contraceptives
□ Menopausal
□ Over weight
Comment: ____________________________________
Do you experience any of the following:
□ Blurring □ Diplopia
□ Photophobia
□ pain
□ Inflammation □ Cataract
□ Glaucoma □ Headache □ Unusual Discharges
Comment: ____________________________________
_____________________________________________
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□ Pain
Sensory Function: □ Positive □ Negative
Location: __________________________________
Motor Function: □ Positive □ Negative
Location: __________________________________
Vital Signs: BP: ______ T______P_____R______
Brudzinski’s sign: □ Positive □ Negative
Kernig’s Sign:
□ Positive □ Negative
Reflexes:
Patellar
Biceps
Triceps
Achilles

□ Positive □ Negative
□ Positive □ Negative
□ Positive □ Negative
□ Positive □ Negative

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
_________________________________________________________________________________________
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III. LABORATORY AND DIAGNOSTIC EXAMINATION
Date
Ordered

LABORATORY AND
DIAGNOSTIC

Result

Significance

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IV. NURSING CARE PLAN
DATA

NURSING DX

OBJECTIVES

NURSING INTERVENTIONS

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RATIONALE

EVALUATION

V. DRUG STUDY
Name of Drug
Generic
(brand)

Classification

Dose/
Frequency/
Route

Mechanism of
action

Indication

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Contraindication

Side effects

Nursing Precaution

VI. SOAPIE (First day)

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VI. SOAPIE (Second day)

14

VI. SOAPIE (Third day)

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VII. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

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VII. PATHOPHYSIOLOGY
Name of Patient: __________________________________ Age: ______________ Sex _________________
Diagnosis: ________________________________________________________________________________
Definition:

Reference:

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