BATES ASSESSMENT TOOL:

MENTAL STATUS
APPEARANCE

Grooming: ______________________ Attire: ________________________

Personal Hygiene: __________________________________________________
Gait: _______________ Posture: ___________General Body Built: __________

BEHAVIOR
Level of Consciousness:
( ) Awake ( ) Alert ( ) Lethargic
( ) Drowsy ( ) Stupurous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: __________________ Speech: ______________________
Mood: ________________________ Affect: _______________________

COGNITION

Oriented: ( )Person ( ) Place ( ) Time ( ) Confused ( )

Sedated
( ) Alert ( ) Restless ( ) Lethargic ( ) Comatose
Recent Memory: ____________________________________________
Remote Memory: ___________________________________________

THOUGHT PROCESS

Thought Content: ( ) Logical ( ) Consistent

Client’s Perceptions: ( ) Reality-base ( ) Congruent with others
( ) Others: _______________
Suicidal Thoughts/Ideation: ( ) Present ( ) Absent

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( ) Normal ( ) Flushed ( ) Pale ( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others: _________________________
Texture: _______________________ Tone: _________________________
Lesions: ( ) Yes, site: ______________ ( ) No
PALPATION
Moisture: ____________________ Temperature: _______________________
Turgor: ___________________________
Edema: ( ) Absent ( ) Present, site: _______________________
( ) Mild ( ) Moderate ( ) Severe
Pruritus: ( ) Yes, site: _________________ ( ) No
Wound incision/pressure sore site: ___________ Dressing type: ______________
Odor: ( ) None ( ) Mild ( ) Foul
Drainage/Exudates: ( ) Serous ( ) Sanguinou ( ) Serosanguinous
Color: ( ) Yellow ( ) Creamy ( ) Green ( ) Beige/tan

NAILS
INSPECTION
Color: ____________ Texture: ______________ Configuration: ______________
Symmetry: ______________ Cleanliness: ______________

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: _____________________
Hair Color: _______________ Thinning: ( ) Yes ( ) No
PALPATION
Temporal Artery: _________
Cranium: _______________ Scalp: _______________
Hair Texture: _______________
Maxillary & Frontal Sinuses: __________________________

EYES
INSPECTION
Conjunctiva: R: _________ L: _________ Sclera: R: ________ L: _________
Cornea: R: _________ L: _________ Iris: R: ______ L: _________
Ptosis: R: _________ L: _________
Visual Fields: R: _________ L: _________
Extraocular movements: : R: _______ L: _______
Pupil: Color: R: _________ L: _________ Size: R: ______ L: _________
Response to Light & Accommodation: R: _________ L: _________

NOSE
INSPECTION
External Nose: __________________________
Nostrils: R: _________ L: _________

MOUTH
INSPECTION
Mouth & Throat Mucosa: ________________Tongue: ____________________
Teeth and Gums: ____________________________
Floor of Mouth:_____________ Palate: ___________ Uvula: ______________
Lesions and Ulcers: ( ) Yes, site: ____________ ( ) No
Salivary Glands: _________________

FACE
INSPECTION
Spasms: ( ) Yes, site: __________ ( ) No
Tics: ( ) Yes, site: __________ ( ) No
Lesions: ( ) Yes: ( ) Mild ( ) Moderate ( ) Severe ( ) No
Facial Paralysis: ( ) Yes R: _________ L: _________ ( ) No

EARS
INSPECTION
Tympanic membrane: R: Intact ( ) Yes ( ) No L: Intact ( ) Yes ( ) No
Tragus of Ear: R: _________ L: _________
Canal: R: _________ L: _________
Lesions: ( ) Yes, site: ___________ ( ) No
Discharges: ( ) Yes, amount: ________ ( ) Left ( ) Right ( ) Both ( ) No

NECK
PALPATION
Thyroid gland size: ________________ Shape: ________________
Tenderness: ________________ Nodules: ________________
Position of Trachea: ________________
Cervical Lymph Nodes: __________________________________

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: ___________
Pattern: ( ) Shallow ( ) Dyspnea ( ) Tachypnea ( ) Shortness of
Breath
Chest Symmetry: ( ) Even ( ) Uneven
Chest Deformities: ( ) Scoliosis ( ) Kyphosis ( ) Kyposcoliosis
PALPATION
Chest: ( ) Masses, site: ____________
( ) Bulges, site: ____________

( ) Muscle Tone, site: ______________

( ) Crepitus, site: ______________
( ) Areas of Tenderness, site: ______________
( ) Subcutaneous Emphysema, site: ______________
Excursion: ( ) Respiratory: R: ______cms. L: ______cms.
PERCUSSION
Notes elicited: ______________ Site: __________________
AUSCULTATION
Excursion: ( ) Diaphragmatic: R: ______cms. L: ______cms.
Breath Sounds:
Normal: ( ) Bronchial ( ) Bronchovesicular ( ) Vesicular
Adventitious: ( ) Crackles-Coarse, site: ____________
( ) Crackles-Fine, site: ____________
( ) Stridor, site: ____________
( ) Rhonchi/Gurgles, site: ____________
 ( ) Wheezes, site: ____________
( ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
( ) Bronchophony ( ) Egophony ( ) Whispered
( ) Pecteriloquy ( ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough: ( ) Yes: Type: ( ) Productive:
Color of Sputum: ___________ Amount: __________
( ) Non-productive ( ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: ____________ L: ____________
AUSCULTATION
Carotid Arteries: Bruits: ( ) Absent ( ) Present
Jugular Vein Distention: ( ) Yes: _______cms. ( ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): ___________________
Thrills: ( ) Present ( ) Absent
PALPATION – Perfusion: Capillary Refill: _____seconds
Murmurs: ___________

PULSES
( ) Regular ( ) Strong ( ) Irregular ( ) Weak ( ) Absent
( ) Doppler ( ) Pacemaker
Radial: R: ____________ L: ____________
Pedal: R: ____________ L: ____________
Apical: R: ____________ L: ____________
BP: R: ____________ L: ____________
GASTROINTESTINAL SYSTEM
Mouth:_____________________________________________________________
Throat:_____________________________________________________________

ABDOMEN
INSPECTION
Contour: ____________________________
Symmetry:__________________________
Gastrostomy (specify): _______________________________________________
AUSCULTATION
Bowel sounds:( ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate:_________per minute
PERCUSSION
Notes: ____________________________
Site:__________________________________
PALPATION
Abdomen: ( ) Tender( ) Soft/Non-Tender ( ) Firm ( ) Rigid
Mass: ( ) No ( ) Yes
Ascites: ( ) No ( ) Yes
Girth: ________________ Inguinal
Area:__________________________

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry:___________________________
Deformities:________________________
Others: _________________
Peripheral pulses:
Upper Extremities: Radial: R: ____________ L: ____________
Ulnar: R: ____________ L: ____________
Brachial R: ____________ L: ____________
Lower Extremities: Popliteal: R: ____________ L: ____________
Dorsalis Pedis: R: ____________ L: ____________
Posterior Tibia:R: ____________ L: ____________
Edema: ( ) Yes ( )Pitting (Grade) _________ ( ) No
Temperature: _______________________ Site: __________________________
RANGE OF MOTION: ( ) Yes ( ) No, area: _________________
Deformity:
______________________________________________________________
Discrepancy in Extremity (Leg) Length ( )Yes ______________ ( ) No
PALPATION
( ) Musculature ________________ ( ) Body articulation_____________________
( ) Crepitations ________________ ( ) Heat_____________________________ (
) Swelling ____________________ ( ) Tenderness_______________________
Normal ROM of extremities: ( ) Yes ( ) No
( ) Weakness ( Paresis) ( ) Paralysis
( ) Contractures ( ) Joint Swelling
( ) Pain: ( ) Bone Pain ( ) Muscle Pain ( ) Joint Pain
( ) Others: __________________________________________
Hand Grasps: ( ) Equal ( ) Unequal ( )Weakness ( ) R & L
Leg muscles: ( ) Equal ( ) Unequal ( ) Weakness ( ) R & L

NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)

Optic Nerve (CN II)

Oculomotor (CN III)

Trochlear (CN IV)

Trigeminal Nerves (CN V)

Abducens Nerve (CN VI)

Facial Nerve (CN VII)

Acoustic Vestibulocochlear Nerve (CN VIII)

Glossopharyngeal Nerve (CN IX)

Vagus Nerve (CN X)

Spinal Accessory Nerve (CN XI)

Hypoglossal Nerve (CN XII)

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: ( ) Yes ( ) No
Detect Vibration: ( ) Yes ( ) No
Discriminate Light Touch: ( ) Yes ( ) No
Detect Temperature: ( ) Yes ( ) No
Detect Stereognosis: ( ) Yes ( ) No
Detect Graphesthesia: ( ) Yes ( ) No
Two-Point Discrimination: ( ) Yes ( ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
______________________________________________________________
Insertion Tendon of Triceps (C7 to C8)
______________________________________________________________
Insertion Tendon of Brachioradialis (C5 to C6)
_____________________________________________________________
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_____________________________________________________________
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
______________________________________________________________
________

SUPERFICIAL REFLEXES
 Abdominal (upper T8 to T10, lower T10 to T12)
______________________________________________________________
Cremasteric Reflex (L1 to L2)
______________________________________________________________
Plantar Reflex
______________________________________________________________

GENITOURINARY
PERIANAL REGION
INSPECTION

( ) Hemorrhoids: ( ) Bleeding ( ) Not

( ) Fissures ( ) Scars ( ) Lesions ( ) Rectal Prolapse
( ) Fistula ( ) Discharge ( ) Blood in stool

PALPATION
( ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution: _____________________________________________________
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance: _________________________________________
Bumps: ( ) Yes, site: ___________ ( ) No
Blisters: ( ) Yes, site: ___________ ( ) No
Lesions: ( ) Yes, site: ___________ ( ) No
Redness: ( ) Yes, site: ___________ ( ) No
Scrotum: R: ____________ L: ____________
Urine: Color: ______________________ Character: ___________________
Frequency per day: ___________ Amount: _____________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Others (specify): _________________________

FEMALE GENITALIA
INSPECTION
Mons Pubis: ___________________ Labia Majora: ___________________
Labia Minora: __________________Clitoris: ____________________________
Vagina: ___________________________ Urinary Meatus: _________________
Skene’s and Bartholin’s Glands: _______________________________________
Urine: Color: ___________________ Character: _____________________
Frequency per day: ___________ Amount: ___________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): _________________ Other:____________________
LMP: ___________________________ ( ) Vaginal Discharges: ___________
Menstrual Problems:
( ) Amenorrhea ( ) Dysmenorrhea ( ) Menorrhagia
( ) Metrorrhagia ( ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche: _____________ Length of Cycle: ____________________
Menopause: ___________________Last Pap Smear: ____________________
Monthly Breast Self Examination ( ) Yes( ) No
Method of Birth Control: _____________________________
Obstetrical History: G___ P___A___L___ AOG______
POP: ______ Weight: ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: ___________________
Urine Test Result: ___________________ Pregnancy Test: _________________
( ) Albumin _______ ( ) Sugar ________
( ) Protein _______ ( ) RBC ________ ( ) Pus ________
Bleeding: ( ) Yes, amount: ___________ ( ) No
Uterine Discharges:
Rubra: Color_______ Amount________ Odor_________
Serosa: Color_______ Amount________ Odor_________
Alba: Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: _____________________________________________________
Coping Mechanism: _________________________________________________
Support System: ___________________________________________________
Calm: ( ) Yes____________________ ( ) No______________________
Anxious: ( ) Yes____________________ ( ) No______________________
Angry: ( ) Yes____________________ ( ) No______________________
Withdrawn: ( ) Yes____________________ ( ) No______________________
Irritable: ( ) Yes____________________ ( ) No______________________
Fearful: ( ) Yes____________________ ( ) No______________________
Religion:_______________________________ Restrictions:_________________
Feeling of Helplessness: ( ) Yes ( ) No
Feeling of Hopelessness: ( ) Yes ( ) No
Feeling of Powerlessness: ( ) Yes ( ) No
Tobacco Use: ( ) Yes____________________ ( ) No______________________
Alcohol Use: ( ) Yes____________________ ( ) No______________________
Drug Use: ( ) Yes____________________ ( ) No______________________

NUTRITION
General Appearance: ( ) Well Nourished ( ) Malnourished
( ) Emaniciated ( ) Other
Body Built:___________ Weight: ___________ Height: ___________
Diet:________________ Meal Pattern:___________________________
 ( ) Feeds Self ( ) Assist ( ) Total Feed

Mastication/Swallowing Problem ( ) Yes_________ ( ) No_________

Dentures: ( ) Yes ( ) No
Appetite: ( ) Increased ( ) Decreased ( ) Unusual
Decreased Taste Sensation: ( ) Yes ( ) No
Nausea: ( ) Yes ( ) No
Stool frequency: ___________________ Characteristics: ___________________
Last Bowel Movement: ______________
NGT/ Gastrostomy:__________________

VENOUS ACCESS RECORD

Date Gauge (color)/
Date Reaso
# Site Inserte Fluid Number of
Removed n
d Drops

PAIN ASSESSMENT
Location of pain: _____________________ Frequency: __________________
Intensity Pain Scale(0-10): _________________ Quality: _____________________
Onset: (When did your pain started?) ___________________________________
Duration:_______________________ Body Reaction: _______________________
Alleviating Factors:
_______________________________________________________
Precipitating factors:_________________________________________________
Special Assessment Devices
( ) Wheelchair ( ) Contacts ( ) Venous Access device
( ) Braces ( ) Hearing aid ( ) Epidural catheter
( ) Cane/ Crutches ( ) Prosthesis ( ) Walker
( ) Glasses
Others:____________________________________________________________

SELF-CARE
Need Assist With:
( ) Ambulating ( ) Elimination
( ) Bed Mobility ( ) Meals
( ) Hygiene ( ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Use ( ) Signs & Symptoms to Report
( ) Ordered Therapies ( ) Lifestyle Change
( ) Diagnosis / Disease ( ) Rehabilitation Measures
 ( ) Pain Management ( ) Hygiene / Self care
( ) Hospital Referrals ( ) Diet or Nutrition
( ) Community Referral ( ) Mobility / Ambulation
( ) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with special
nursing care instruction to be given to the client like, dosage, time, frequency.
__________________________________________________________________
__________________________________________________________________