Ateneo de Sambonnga Zfniversity College of Nursing BATES ASSESSMENT TOOL MENTAL STATUS. ‘APPEARANCE Grooming: aa) Attire: pond Personal Hygiene: Bal a Gait omure: Ct General Body Bui BEHAVIOR Level of Consciousness (Awake () Alert (7 Letharaie () Drowsy () Stupurous oF unresponsive () Aware and responsive of internal and extemal stimuli Facial Expression: i, Speech: Mood: Buk. Affect: COGNITION Oriented: (Person () Place ()Time —_( ) Confused _( ) Sedated CAlert (yResties () Lethargic ( ) Comatose Recent Memory: Remote Memory Aig = ‘THOUGHT PROCESS ‘Thought Content: (-yLosical () Consistent Cent's Perceptions: (,yRealty-base _( ) Congruent with others C) Other Suicidal Thoughtsideation: Present C/Absent INTEGUMENTARY SYSTEM SKIN INSPECTION Color: ()Nommal ()Fiuhed Fale () Cyanotic () Jaundiced ( ) Other Texture Tone Lesions: CVs, Ne PALPATION Moisture: Temperature: Nj To SERA Edema: (yAbsent— (-) Présent, ste:Drartuns( ) Ver ste TINo Wound inciion/pressure sore site: JA Dresing type:_N/A Odor: (None () Mild) Foul Drainage/Esudates: ()Serous —() Sanguinous_( ) Serosanguinous Color: () Yellow ()Creamy —() Green ()Beigeltan NAILS INSPECTION Color: POW Texture: mui) ‘Configuration: avrg Symmetry: Baand ‘Ceanines: wit aoa HEAD AND NECK HEAD INSPECTION Head! Structure and symmetry: ita! Hair Color Bac ‘Thinning: (Ver (No PALPATION Temporal Artery: _Naxmal Cranium: Fa Scalp ar Tonner ia al Maxillary & Frontal Sinases:_ (Tray EVES INSPECTION Conjunetiva: R:qarmal _ A:_normal, —Sclera: Re wim Corea Re Ram et ee Pros & Visual Files Re Extraocular movernentsr: R: lured Ti _gurma upis Color: Re Blah Cane Size: Re L Response to Light & Accommodation: (vit Lr NOSE INSPECTION External Nose: kU] Nort: Re Wk Ls gages MouTH INSPECTION Mouth & Throat Mucosa: SaFongue: Teeth and Gum Floor of Mout: NUN alate: Uvules sun Lesions andl Ulers ( ) Wes ster VINO Salivary Glands: FACE INSPECTION Spasins: (Yes, sit Tics) Yes, site: Lesions. (} Yes:Facial Paralsin( ) Ves T TINo EARS INSPECTION ‘Tympanicmembrane: Rs Intact (Wes ()No L:intact () Yes ()No Tragus of Ear: RM) L: sta Corl Ste at Lesions: ( ) Ves, site: ‘No Discharges: () Yes, amount C) Left () Right (Both (No NECK PALPATION Thyroid gland size:_ AHO Shape: Nowa) Tendemess MI. Nodule Wve Postion of Trachea Cervical Lymph Nodes RIN RESPIRATORY SYSTEM LUNGs INSPECTION Respiration Rete: Patter: ( ) Shallow (“Dyspnea ( ) Tachypnea ( ) Shorines of Breath Chest Symmetry: (Even () Uneven Chest Deformities: (ZF Scolios () Kyphosi» ( ) Kyposcolinis PALPATION Chest: C) Masses, site (Bales, site: () Muscle Tone ste ()Crepitus ste: () Areas of Tenderness ite (Subcutaneous Emphysema; ie Excunion: (JRewpiratory: RA ems. U5 arm, PERCUSSION Notes elt site: AUSCULTATIO} Excursion: (Diaphragmatic Re) cms, L:_2 ems. Breath Soundh Normak () Bronchial () Bronchovescular—_( ) Vesicular Adventitious ( ) Crachls-Coare st () Grachles-Fine, st (Strider, ste: () RhonchilGurgles, Cheeze, ste: NAR — (© Pleural Friction Rb, ste ther Abnomal Findings Voice Resonance © Bronchophony——() Egophony (Whispered (Pederiloquy (Pleural Friction Rub Chest Abnommaiity Location (stateCoughs () ver Type: (7 Produdive: Color of Sputum: firtug,_ Amount: ()Non-productive —() No CARDIOVASCULAR SYSTEM NECK VESSELS PALPATION Carotid Artery: Re Ntna) _L:_Mingh AUSCULTATION Carotid Arteries: Bruitsi( “Absent ( ) Present Jugular Vein Distention: (") Yes cms. No HEART INSPECTION Point of Maximal Impulse (PMD: Thrill: () Present (Absent PALPATION ~ Perfusion: Capillary Refi L_seconds Murmurs PULSES () Regular (7Strona ()imeguiar —() Weak) Absent (Doppler ©) Pacemater Radial: Pedal: R Apc TE GASTROINTESTINAL SYSTEM ‘ABDOMEN INSPECTION ‘Contour. toy Symmetry:_Mffa astrostomy (specify): Hf AUSCULTATION Bowel sounds: () High-pitched & Gurgiing ( ) Hyperactive ()Low-pitched () Hypoactive CaTympany Rater}-*piandl per minute PERCUSSION i Notes:_Qull Ste Lut AVON Wyse peng PALPATION Abdomen: () Tender (4Soft/Non-Tender ( ) Firm (Rigid Mas JNO (Ves Ascites: (No (Yes Girth: vo Inguinal Area:_1 tun}, wor! MUSCULO-SKELETAL SYSTEMINSPECTION Symmetry: Deformities Ninn? Others: Peripheral pubes: Upper Extremities: Radiat: R L. Ulnar: R uy, Brachial Ri L Lower Extremities Popiiteak L DonalsPedis: R: Posterior Tibial Li Edema: () Yes ( )Pitting (Grader. T)Ne Temperature: St RANGE OF MOTION:() Ver __() No, area: Deformity Discrepancy im Extremity (Leg) Lenath ( ver Ne PALPATION| () Musculoture () Body articulation () Grepitations (C) Heat. () Swelting (. Tendemess Normal ROM of extremities.) Ves ‘(Ne (C) Weakness (Baresi) () Paralysis (Contracture CO Joint Sweling (Pain: () Bene Pain (() Muscle Pain (Joint Pain. () Others: Hand Grosps: () Equal) Unequal ( )Weaknes ()REL Leg muscles: () Equal }.Unequal ()Weaknes ()REL NEUROLOGIC SYSTEM (CRANIAL NERVES Olfactory Nerwe (CN 1) Optic Nerve (CN I, Saulomotor (CN Tl Wi Trochlear (CNW) NXtol_ ign EE Eee Trigeminal Nerves (CNV) Now wane Ong Honky ‘Abducens Nerve (CN VD) NWO Vatcat devia | Facial Nerve (CNVI) ‘Acoustic Vestioulocochlear Nerve (NVI) Glosopharyngeal Nerve (CN XQ)VagusNewe@N Spinal Accesory Nerve (CNXD Ig ee Hypoglewal Newe (CN ID (CEREBELLAR FUNCTION SENSORY SYSTEM Discriminate Light Pain: Ove QO Detect Vibration: ves Q Discriminate Light Touch: (yes QO Detect Temperature: re QO QO 0 oO No No No Detect Stereognosis: QOves Detect Graphesthesio: (ves Two-Point Discrimination: Oves DEEP TENDON REFLEXES Insertion Tendon of Biceps (C5 to Co) Insertion Tendon af Treeps (Cro GB) Insertion Tendon of Brachioradialis (5 to Ce) iyertar Tendon of QuaicepKnee lr (L210 La) insertion Tenkdon of Achille Anil Jer (Sito 52) SUPERFICIAL REFLEXES ‘Abdominal (upper Ts to Tio, lower Tio to Tr) (Gremasteric Reflex (Lito L2) Brantar Reflex GENITOURINARY. PERIANAL REGION INSPECTION ()Hemorhoids: (Bleeding ("Not () Fisures ()Scars—C) Lesions ( ) Rectal Prolapse ) Fistula () Discharge _() Blood in stool PALPATION ©) Rectal MassesMALE GENITALIA INSPECTION Hair Distribution: Penis; Dorsal Vein. (Ver (No Urethral Meatus Appearance: Bumps: ( ) Ves, site: CFNo Blisters: () Ves, site: QNo Lesions: () Yes, ste: No sertunttet (3 Yes te (CANo Scrotum: Tagged Urine: oe or Character: Frequency per day: ‘Amount: ()Anuia —() Hematuria () Dysuria ( ) Incontinence () Catheter (Type): Others (spect) FEMALE CENITALIA INSPECTION Mons Pubs: Labia Majora: Labia Minor Citoris Vagina: Urinary Meat Sheene’s and Bartholin’s Glan Urine: Color Character: Frequency per day: Amount () Arua () Hematuria () Dysuria—( ) Incontinence () Catheter (Type): then. Lp, Vaginal Discharges Menstrual Problems: ()Amenorthea —(-) Dysmenorthea__(.) Menorthagia () Metrorthagia ) Bre Menstrual Syndrome Others (pecity) ‘Age of Menarche:, Lenath of Cycle: ‘Menopause: Last Pap Smear: Monthly Breast SeF Examination —( ) Ves ( ) No ‘Method of Birth Control Obstetrical History: C_P_A_L_ ‘AOC. Pop: Weight: Leopoid’s Maneuver Urine Test Result © Albumin () Protein Bleeding: (Ves,amount: Uterine Discharges: Rubra: Color____ Amount, Serorar Calor.PSYCHOSOCIAL Recent Stress Coping Mechanism: Support System: _W Cam: (Tes (No. Anxious: ( 3¥es (Ne. Angy: (Ve No. Withdrawn: ) Yes ON. Intable: (4 Ves CINo. Fearful (Yes (No. Relion, gat NL sin Feeling of Helplesines: (Ver () Ne Feeling of Hopelesnes: (Ver (Ne ON Feeling of Powerlesness: (“Ves 0 Tobacco Use:( ) Yes, ONo. Alcohol Use: () Ves ONo, Drug Use: ( ) Ves ON: NUTRITION General Appearance: (JWellNourithed —( ) Mainourished () Emaniciated =) Other Body Buitt; \Uoi\ Weight: 1° ts Height: Diet: SNE Meal Pattern: T) Feeds Sel (Ait) Total Feed Mstication/Sucilowing Problem (Ves (re. Dentures: ()¥er (NO Appetite: () Increased (Decreased ( ) Unusual Decreoied Taste Seniation:(¥es ( )No Nausea: (WVer ONO Stool frequency ste Bawtl_ Characteristic Mk Let Bowel Movement: AA NGT/ Gastrostomy:W/k VENOUS ACCESS RECORD Date Gauge (color) | Date # | Ste | inserted | FS | Number of Drops | Removed | BAIN ASSESSMENT Reason Location of pai AY Frequency. whl Wf (Dagha. Intenity Pain Scale(-t0): ual Cnet: When di your pain torked?) WOUDuration: 7. NO Body Reaction: Alleviating Factors: FIA, Precipitating factors_Y/® Special Assessment Devices () Wheelchair () Contacts () Venous Access device () Braces () Hearing aid () Epidural catheter () Cane/ Crutches) Prosthesis ©) Walker © Glasses Other SELF-CARE Need Assit With (Q)Ambutating (©) Bimination (JBed Mobility, G Meals CrHygiene Q Dresing PATIENT EDUCATION (Safety / Restraint Use ( ) Signs & Symptoms to Report (J Ordered Therapies —_( ) Lifestyle Change ©) Diagnosis! Disease) Rehabilitation Measures ()Pain Management.) Hygiene / Self care (Hospital Referrab —(-) Det or Nutrition () Community Referral ( ) Mobility / Ambulation ) Medication Specify Plan of Care intended Example medications (Lit Down all medications to be taken at home with special nursing care instruction to be given to the client like, dosage, time, frequency. O, YW