American University of Beirut - Hariri School of Nursing 1

NURS 300- Nursing Care of Adults & Older Adults I

Health Assessment Tool

Assessor: __Huda Hayek____________________ Interview Date:

___16/11/19_________________

Patient’s Initials: __O.A___________ Bed Number: _819B______ Age: _42______ years

Gender:  Female  Male Physical Activity: Sedentary  Active
Marital Status:  Single  Married  Widowed  Divorced

Source of information:  Patient  Family  Chart

Reliability:  Good  Fair  Poor
Medical History: _Cancer, dyslipidemia, hypertension, kidney stone
___________________________________________________________
Surgical History:
__none__________________________________________________________
Current Medical Diagnosis: __Sore throat, mucositis, odynophagia
_______________________________________________
Vital Signs: Tp: _36.8____˚C, HR: _92____ bpm, RR: __16___ bpm, BP: _104/56_____ mm Hg
Chief Complaint(s):
__patient was admitted for sore throat, febrile neutropenia, and
mucositis______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______
History of Present Illness:
Diffuse B-cell lymphoma
Dyslipidemia
HTN
Kidney stone
Lymphadenopathy
Sore throat

HEALTH PERCEPTION AND MANAGEMENT

Regular physical checkups:  Yes  No
Smoker:  Yes No. If yes, packs/day: _____ Years _______
Narjileh use:  Yes  No. If yes, frequency/week ____________
Alcohol use:  YesNo. If yes, frequency/week____________
Other drugs:  Yes  No. If yes, type, frequency, amount: __________________
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

Neurological Assessment
Oriented to:  Time Place  Person
Communication/ speech:  WNL  Dysarthria  Aphasia (Expressive, Receptive, or
global):
Pupils:
Equal:  Yes  Right larger  Left larger
Reaction:  Brisk  Sluggish  Right no reaction  Left no reaction
Accommodation:  Right  Left
Glasgow Coma Scale: /15
Eye Opening to 4 Spontaneous
3 Verbal Command
2 Pain
1 No response
Verbal Response to 5 Oriented, converses
4 Disoriented, converses
3 Use inappropriate words
Muscle Tone and Strength: (Check applicablesounds
2 Incomprehensible and note strength score)
1Tone
No response
WNLto
Motor Response Flaccid Spastic
6 Verbal Command Tremors Strength Score
Neck  5 Localized pain
RUE  4 Flexes and withdraws
LUE  3 Decorticate (Flexes abnormally)
RLE  2 Decerebrate (Extends abnormally)
LLE  1 no response
Muscle Strength:
5= Within Normal Limit , 4= 75% normal 3= 50% normal, 2=25% normal,
and 1=Paralysis

Respiratory Assessment
Respiratory Effort:
 Relaxed and Regular  Labored  Pursed Lip Breathing  Painful Respiration

 Dyspnea at Rest  Dyspnea with minimal effort  Dyspnea with moderate exertion 
Dyspnea when walking
Oxygen:  Room air  _____ liters Nasal Cannula  ____ liters Face mask
 Non-invasive ventilation (CPAP / BIPAP)
 Tracheostomy
Others:
Respiratory Rate: _16____bpm SpO2: ___95___ %
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

Cough:  None  Non productive/dry  Productive  Productive sounding but with no sputum
Sputum:  Thick  Thin  Foamy Color: _____________________
Respiratory Rhythm:
 WNL  Tachypnea  Bradypnea  Apnea

 Regular pattern of increasing rate and depth, followed by

decreasing rate and depth, followed by apnea (Cheyne Stokes)

 Regular, abnormal, rapid and deep respiration (central

neurogenic hyperventilation)

 Regular, abnormal, prolonged inspiration with a pause or sigh

with periods of apnea (Apneustic)
Breath Sounds Specify location next to each abnormal sound as per figure
 Clear  Decreased  Crackles  Gurgles/Rhonchi  Wheezes  Friction rub  Absent
___________________________________________________________________

Cardiovascular Assessment
Skin Texture:  Warm/Dry  Cool  Clammy/Diaphoretic
Skin Turgor:  WNL  Tenting
Capillary Refill:  < 3 seconds  > 3 Seconds
Apical Pulse Rhythm:  Regular  Irregular

Apical Pulse Rate: __Not assessed_bpm

Blood Pressure: Right __104/56______ mm Hg Left __________ mm Hg

Heart Sounds:
 Normal S1S2  S3  Valvular click  Murmur
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

Peripheral Pulses (Specify Right, Left, or Both)

Brachial  NL  Diminished ---------
Radial  NL  Diminished ---------
Femoral  NL  Diminished ---------
Popliteal  NL  Diminished ---------
D. Pedis NL  Diminished ---------
Tibial  NL  Diminished ---------

Edema (Specify Right, Left, or Both)

Hands  No  Pitting ------- Grade: --------------------  Non pitting --------
Knee  No  Pitting ------- Grade: --------------------  Non pitting --------
Legs  No  Pitting ------- Grade: --------------------  Non pitting --------
Ankle  No  Pitting ------- Grade: ----1----------------  Non pitting --------
Abdomen  No  Pitting ------- Grade: --------------------  Non pitting --------
Scrotum  No  Pitting ------- Grade: --------------------  Non pitting --------

Gastrointestinal Assessment
Oral Mucosa:  intact  Moist  Dry  Pink  Pale
Tongue:  WNL  Pink  White patches
Abdomen:  WNL  Distended  Ascites  Abdominal Incision  Pain, if yes score ___
Bowel Movements:  WNL  Diarrhea  Constipation  Incontinence
Last Bowel Movement: -----------
Nausea  No  Yes, describe ______________________________________________
Vomiting  No  Yes, describe _____________________________________________
Nutritional intake:  Adequate  Inadequate
Bowel sounds:  WNL  Hypoactive  Hyperactive  Absent

Gastric Tubes:  NG  Jeujenostomy  PEG  Nasoduodenal tube

Tube Feeding: Type __________________ Amount ___________ per hour and via _________
 Intermittent or  Continuous drip
Stoma:  Colostomy  Ileostomy
Stoma status: Pink viable  Red  Deep Red
 Dusky  Dark  Retracted below skin

Genitourinary Assessment
Assessment of urination:  WNL  Burning  Frequency  Urgency  Bladder
Distention  Pelvic pain/discomfort  Flank pain  Stoma  Others: _________
Continence:  Yes  Incontinence with coughing  Rarely incontinent
 Regularly incontinent
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

 Foley catheter  Suprapubic catheter  Condom catheter  Urinary Stents

Urine Output:  WNL  Polyuria  Oliguria  Anuria
Urine Color:  Yellow  Amber  Orange  Dark Amber  Pink  Red tinged  Grossly
bloody
Urine characteristics:  Clear  Cloudy  Sediment  Abnormal odor

Skin Integrity Assessment

Skin Color:WNL  Pale  Jaundice  Dusky  Cyanotic
Skin is:  Intact  No, see below

Signs and symptoms of inflammation/ infection:  Redness  Tenderness  Warmth 

Swelling Location(s): ________________________________________

 Ecchymosis  Petechiae  Moles  Abrasions  Burns

 Lacerations  Pressure Injury  Wound  Surgical incision
Location(s): ________________________________________

Pain Assessment COLDSPA

Pain:  Yes  No
Characteristics of pain:  Acute  Chronic  Intermittent  Constant
Onset of pain ___one week ago_____________________________________________
Location(s):___mouth_____________________________________________
__
Duration: ________________ Severity on a scale 0 to 10: _2____
Projection/ Radiation: _________________________
Aggravated by: _eating and swallowing______________________________
Alleviated with: _______________________________
Medications given: fluconazole and magic mouthwash___________________________
Pain is affecting: None  Sleep  Activity  Exercise  Relationships
 Emotions  Concentration  Appetite  Others:

Adapted from: Vrtis, M.C. An easy Guide to Head to Toe Assessment

List of Nursing Diagnoses (Minimum of 5)

1- Acute pain related to sore throat evidenced by patient verbalizes a mild
pain during swallowing
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

2- Impaired nutrition less than body requirement related to sore throat

evidenced by patient lose 10 kgs
3- Risk for bleeding evidenced by thrombocytopenia evidenced by low platelet
(40,000)
4- Impaired swallowing related to sore throat and mucositis evidenced by
patient verbalizes a difficulty in swallowing
5- impaired skin integrity related by low platelet evidenced by bruising
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

Diagnostic tests

A. Respiratory

Chest X-ray
No□ Yes If yes, results____________________________________________________
Arterial blood gases
No □ Yes If yes, results____________________________________________________
Sputum analysis/culture
□ No Yes If yes,
results_pending___________________________________________________
CT scan/MRI / bronchoscopy of the lungs
□No  Yes If yes, results__Reticulonodular interstitial thickening at the right lung base
extending to the pleural surface with small right pleural effusion ______
Others_____________________________________________________________________

B. Cardiovascular
Cardiac Enzyme Analysis No □ Yes If yes, results______________________________
Coagulation Studies: PTT, PT, INR, Bleeding Time □ No Yes If yes, results_PTT=14.1(10-
13sec), PT= 1.2 (0.9-11sec)________
CBC □ No  Yes If yes, results_HgB=9.3g/dl(12-18g/dl), HcT=26%(37-
54%)________________________________________________
ECG  No □ Yes If yes, pattern and results ____________________________________
Echocardiography No □ Yes If yes, results____________________________________
Cardiac catheterization/angiogram  No □ Yes If yes, results___________________
Others_______________________________________________________________________

C. Gastrointestinal
Stool tests / cultures/ Guaiac  No □ Yes If yes, results__________________________
Digital Rectal exam:  No □ Yes If yes, describe________________________________
Gastroscopy  No □ Yes If yes, results_________________________________________
Abdominal ultrasound No □Yes If yes, results_________________________________
Colonoscopy No □ Yes If yes, results ________________________________________
Others_______________________________________________________________________

D. Endocrine
FBS  No □ Yes If yes, results___________ HbA1C No □ Yes results_______________
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NURS 300- Nursing Care of Adults & Older Adults I
Health Assessment Tool

SGOT/ AST  No □Yes If yes, results____________________________________________

SGPT/ ALT  No □ Yes If yes, results____________________________________________
LDH  No □ Yes If yes, results__________________________________________________
Others_______________________________________________________________________
Serum albumin  No □ Yes If yes, results__________ Serum protein  No □ Yes
results___________
Serum bilirubin No □ Yes If yes, results________________________________________
Na  No □ Yes If yes, results_______________ K  No □Yes, results_______________
Mg □ No  Yes If yes, results__1.5mg/dl (1.6-2.5mg/dl)_____________ Cl  No □ Yes,
results______________
T3, T4, TSH
___________________________________________________________________
CT scan/ultrasound of the liver /liver biopsy □ No  Yes
If yes, results__Multiple subcapsular hypodense areas in the liver, could be related to geographic
fat or neoplastic lesions__________________________
Others_______________________________________________________________________

E. Urinary
Urinalysis:  No □ Yes If yes, results____________________________________________
Urine Culture No□ Yes If yes, results__________________________________________
Creatinine No □ Yes If yes, results________ BUN □ No  Yes If yes, results_7mg/dl (8-
25mg/dl)_______
Creatinine clearance No □ Yes If yes, results_________________________________
KUB No □ Yes If yes, results___________________________________________________
PSA blood test:No □Yes If yes, describe___________________________
Blood culture No □ Yes If yes, results__________________________________________
Others_______________________________________________________________________

F. Neurological
□ CT scan/ MRI □ EEG □ Cerebral Angiogram □ Lumber puncture
Others_______________________________________________________________________