FUNDAMENTAL OF NURSING 11 (1610-252)

PATIENT ASSESSMENT GUIDE

Name of Student: ___________________________________ I.D. No.: ______________________________________
Date of Assessment: ________________________________ Date of Submission: _____________________________

Demographic Data
Patient’s Name: _________________________________ MR #r: _______________ Ward/Room / Bed No.: ______________
Age: ______ Sex: Noor
________ Civil Status: _____________ Residence: __________________________________________
Nationality: __________________ Spoken Language: _____________________ Religion ____________________________
Occupation: ______________________________ Highest Educational Attainment: _________________________________

Admission Data Date & Time of Admission:

Mode of admission: Ambulatory _______ Wheelchair ________ Stretcher_______ Others: __________________________
Admitted from: ER: ____ OPD: ____ Transferred In: ____ Specify Unit: ____ Referral: ___________________________
Brought by Relatives: ____________ Police: _________ Red Crescent: _________ Others: ______________

Admission Vital Signs: T= P= R= BP= Height: Weight:

HEALTH HISTORY
Reason for admission: ___________________________________________________________________________________

History of Present Illness: (Chief Complaints as expressed by patient, since when? What was done?
______________________________________________________________________________________________________

Admission Diagnosis/Impression: __________________________________________________________________________

Past Health History (Previous hospitalization): _______________________________________________________________

_____________________________________________________________________________________________________
Family Health History: __________________________________________________________________________________
_____________________________________________________________________________________________________
Allergies – Specific agent: (Food/drugs/ etc.) Describe reaction:

Medications taken at home: (Indicate last dose taken & reason).___________________________________________________

__________________________________________________ ___________________________________________________
__________________________________________________ ___________________________________________________

General Survey
General Appearance: Well nourished: Obese: Ill looking: Emaciated:
T= P= R= BP= Remarks:

MENTAL STATUS: Alert: Confused: Anxious: COMMUNICATION:

Orientation: Time: Person: Place: Arabic: English: Other language:
Stuporous: Lethargic: Irritable: Combative: Speech Impediment: Aphasic:
Comatose: GCS : Others:

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 PHYSICAL EXAMINATION
I. HEAD, EYES, EARS, NOSE, MOUTH, THROAT and NECK:
Head/ EENT & Neck: Recent trauma: Specify cause & site:
Masses (specify site): Lumps (specify site):
• Eyes: PERRLA: Unequal: R mm. L mm. Blind: R L Acuity: Glasses:
Colors: Sclera: Dry: Conjunctiva: Discharges: Odor: Amount:
Redness: Excessive tearing: Itching: Lesions: Bulging: L: R: Sunken: Others:
• Ears: Deformity: Discharges: Purulent: Waxy: Bloody: Color: Amount:
Swelling around ear: Ringing: Hearing Deficit: R: L: Hearing Aid: Others:
• Nose: Septal Deviations: R: L: Congestion: Discharges: Color: Amount:
Epistaxis: Post Nasal drips: Impaired sense of Smell: Anosmia: Obstructions: R: L:
• Mouth / throat: Lips: Pale: Cyanosed: Dry: Cracked: Mucous Membranes: Dry: Inflammed:
Lesions: Bleeding Gums: Ulcers: Dental caries: Missing Teeth:
Sore Throat: Congestion: Hoarse Voice: Dysphagia: Breath: Halithosis: Acetone:
Alcohol: Ammoniacal: Loss of taste: Dentures: Full: Partial: Upper: Lower: Others:
• Neck: Rigid: Mass (specify site): Swelling (site): Anterior: Posterior: Lateral: R: L:
Thyroid enlargement: Enlarged lymph nodes (sites): R: L: Distended neck veins: JVP:

II. RESPIRATION:
Rate Rhythm Depth: Cough: Dry: Productive :
Dyspnea: Tachypnea: Bradypnea: PND: Sputum- Color: Amount: Odor:
Orthopnea: Nasal flaring: Use of accessory muscles: Consistency: Blood stained: Hemoptysis:
Abnormal breath sounds: Wheezes: Crepitations: Rhonchi: Pleural rub:
Hyperresonance: Dull: Flat: Tympanitic:
Chest tube (s) R: L: (+) Tuberculin Test: Date:

III. CARDIOVASCULAR:
Tachycardia: Bradycardia: Palpitations: Capillary refill: Clubbing:
Murmurs: Friction Rub: Cyanosis : Central: Peripheral: Activity intolerance:
Extremities: Edema - Specify site/degree: Varicosities - Specify site: Claudication:
Assistiev devices / Therapies: (Specify sites) Central line: Arterial line:
A-V shunt: Pacemaker:
Existing IV fluid/access: Date started: Type of IVF: Amount: Rate:
Additives: Site & describe condition:

IV. GASTRO-INTESTINAL / Abdomen: Enlarged: Rigid: Distended: Tympanitic: Tough & glossy: (+) Mass:
Prescribed Diet: Appetite: ↓____↑____ NGT/Stoma: Feedings:
Anorexia: Nausea: Regurgitation: Heartburn: Frequency of feedings:
Dysphagia: Flatulence: Hematemesis Vomiting – Amount: Color: Odor:
Bowel Sounds: ↑ ↓ Date of last BM: Color: Diarrhea- Amount: Constipation: Rectal Itching:
Usual time: Frequency: Incontinence: Bloody stools (Amount): Melena: (Amount):
Hernia: Site: Hemorrhoids: Use of Laxatives: Ostomies: (Specify)

V. GENITO-URINARY: Bladder: Distended: Voiding freely:

Frequency: Urgency: Burning: Dribbling: Dribbling: Polyuria:
Dysuria: Retention: Hematuria: Pyuria: Glycosuria:
Pruritus: Hesitation: Incontinence: Catheter: Date inserted:
Urethral discharges: Amount: Color: Odor: Dysmenrrhea: LMP:

VI. NEURO-MUSCULO-SKELETAL:
Seizures: Vertigo: Tremors: Gait: Uncoordinated: Unbalanced: Limping:
Cramps (site): Muscle wasting (site): Deformity(s) (site):
Paresis (site): Paralysis (site): Paresthesia (site):
Joints: Swelling (site): Redness (site): Deformity (site):
Stiffness (site): Tenderness (site): Limitation of movements (site):
Amputation: Arm (site) Leg (site): Prescribed Activity:

VII. INTEGUMENTARY:
Warm Dry Cold : Clammy: Moist / perspiring: Turgor: Good: Poor:
Color Pale: Flushed: Jaundiced: Cyanosed: Reddened areas: Edema:
Petechia : Rashes/scaling: Abrasions: Burns:
Ulcers: Scar (s): Lacerations: Bruises:
Heat: Pain: Loss of sensation:
Hair: Abnormal distribution: Baldness: Alopecia: Receding hairline:
Dandruff: Lice: Nits: Others (specify):

VIII. ENDOCRINE::
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Temperature intolerance: Weight loss: Polydipsia: Polyuria: Polyphagia: Change in voice:
Related diseases: Others:

PAIN / DISCOMFORT: PHYCHOSOCIAL, CULTURAL & SOCIAL FACTORS:

Location: Onset: Severity (Scale of ten): Recent stress: Coping mechanism: Calm: Cooperative:
Radiation: Duration: Anxious: Irritable: Agitated: Violent:
Chronology: Setting: Source of income:
Type: Vague: Stabbing: Pricking: Gnawing: Social problems: Smoker (how long):
Feeling of heaviness: Associated factor: Substance abuse (how long):
Aggravating/ Precipitating factors: Alcohol consumer (how long):
Alleviating/ Relieving factors: Others (specify):

ACTIVITIES OF DAILY LIVING: D Devices (specify):

Assistance needed with: or completely dependent: Casr: Splint: Braces:
Ambulation: Eating: Bathing: Dressing: Traction: Over bed Trapeze: Cane Walker
Elimination: Turning (frequency): Crutches: Artificial limb:

SAFETY PRECAUTIONS:
Side rails: Restraints: Observations: Constant Close

CONTRAPTIONS:
Oxygen support: Existing IV access: Date started:
Type of IVF: Amount: Additives: Rate:
Site & describe condition:
CVP/Arterial line & Site: A-V shunt & Site: Others:

DIAGNOSTIC PROCEDURES: Date Results: Nursing Implications:

LABORATORY INVESTIGATIONS (Most recent)