RLE FORM 001

Cebu Normal University

College of Nursing
Cebu City
NURSING ADMISSION AND ASSESSMENT
Name of Student: ________________________________________ Clinical Assignment:______________
Name of Clinical Instructor: _________________________________ Inclusive Dates: _________________
A.

General Admission Information

Name of Patient: _______________________________________________ Age: ________ Sex:________
Date: _________________ Time: __________ Mode: ______________ Allergies: ____________________
TPR: _______________ BP: ___________ HT: ______ WT: ______ Diet: __________________________
Sleeping Habits: _______________________________ CBC: Yes ___ No ___ Urinalysis: Yes ___ No ___
Property:

Glasses ___________

Contact Lenses _________

Dentures: _______

Prosthesis __________

Ring _________

Watch ______

Money _________
Other ______________________________________________________________________
Valuable to Business Office: ____________________________________________________
Physical Appearance:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Behavior Exhibited: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Content of Conversation: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________
Physician In-Charge
B.

Admission Interview
1. Patients perception of reason for admission:
________________________________________________________________________________
________________________________________________________________________________
2. Patients symptoms as he/she sees them : ______________________________________________
________________________________________________________________________________
________________________________________________________________________________

3. Problems in Daily Living Created by Symptoms (as patient views them)

________________________________________________________________________________
________________________________________________________________________________
4. Past Medical History (especially as it relates to P.I.)
a. Medical ________________________________________________________________________
b. Surgical
______________________________________________________________________________________
c. Allergies ________________________________________________________________________
d. Medication ___________________________________________________________________________________
e. Traumatic injuries ________________________________________________________________
f. Orthopedic ______________________________________________________________________
g. Other (psychiatric, etc) ____________________________________________________________
5. Habits:
a. Smoking _____________ Alcohol _______________________ Drugs _______________________
b. Eating __________________________________________________________________________
c. Social Activity ________________ Physical Exercise _____________________________________
d. Rest / Sleeping _______________________________________________________________________________
_______________________________________________________________________________
e. Sexual _________________________________________________________________________
______________________________________________________________________________________________
f. Elimination ____________________________________________________________________________________
6. Social Economic History:
a. Native Language _________________________________________________________________
b. Education _______________________________________________________________________
c. Occupation ______________________________________________________________________
d. Financial Status (what is the impact of current hospitalization)
_________________________________________________________________________________
_________________________________________________________________________________
e. Civil Status: Married ____
f. Living Situation:

Single ____

Divorced ____

Widowed ____

Lives Alone _______________________________________________________

Living with others (specify) ___________________________________________

7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)
_________________________________________________________________________________
_________________________________________________________________________________
8. Primary Physicians Admitting Diagnosis (indicate P= Probable, C= Confirmed)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

C.

Nursing Review of Systems (circle the appropriate symptoms)

1.

EENT: Headaches
Eye Pain
Sinus Pain
Sore Throat

Hearing Loss
Eye infection
Facial Pain
Nasal-tracheal Pain

Visions
Diplopia
Blurring
Epistaxis
Bleeding Gums
Dentures
other ____________________________

2.

CARDIO-RESPIRATORY: Chest pain (site) _______________________________________

Chest pain with exertion
Dyspnea on excretion
Nocturnal Dyspnea
Edema
Hypertension
Palpitation
Known Murmur
Cough
Sputum
Hemoptysis
Pleuritic Pain
Diaphoresis
Last X-ray __________________________________ EKG __________________________

3.

GASTRO-INTESTINAL:
Thirst
Heartburn
Abdominal Pain
Hemorrhoids

4.

Nausea
Difficulty in swallowing
Jaundice
Hernia

GENITO-URINARY:
Dysuria
Nocturia
a.

b.
c.

5.

Vomiting
Hematemesis
Flatulence
Constipation
Diarrhea
Tarry Stools
Other: _________________________

Polyuria
Burning

Frequency
Hematuria

Urgency
Stones

Female Genital Tract Menstrual History: Age of Onset: _____________________

Frequency __________
Regularity __________
Duration _____________
Date last period __________________ Post Menopausal Bleeding ______________
Age ________________________ Symptoms ______________________________
G _______________________ P __________________ Ab ___________________
Male Genital Tract:
Penile Discharges
Lesions
Pain
Testicular Swelling
Other ____________________________________________
Last Serology Test __________________________________

MUSCULO-SKELETAL:
Muscle pain
Extremity pain
Joint pain
Back pain
Joint Swelling
Neck Pain
Stiffness
Limited motion
Redness
Sprains
Deformity
Other _____________________________________________________________________
X-rays ____________________________________________________________________

6.

NERVOUS:
Convulsions
Syncope
Dizziness
Vertigo
Tremor
Speech Difficulty
Limp Paralysis
Parasthesis
Muscle atrophy
Muscle Tenderness
EEG _____________________________________________________________________
Other ____________________________________________________________________

7.

8.

ENDOCRINE:
Goiter
Exopthalmos
Change in body Contour

Tremor
Voice Change
Infertility

Heat or Cold Intolerance

Polydipsia
other ________________

EMOTIONAL:
Anxiety
Depression
Fear
Anger
Frustration
Other (specify) __________________________
Notes: ____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

D. Nursing Observation
1. HEENT
a. Symmetry
b. Eyes and Pupils
c. Ears
d. Mouth and Throat
e. Lymph Nodes

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

2. RESPIRATORY
a. Depth and Rate
b. Breath Sounds
c. Chest Expansion

______________________________________________________________
______________________________________________________________
______________________________________________________________

3. CARDIO-VASCULAR
a. Blood Pressure
(R) _________ (L) _________ Lying _________ Standing ___________
b. Apical pulse rate and regularity
__________________________________________________
c. Pedal Pulses rate per minute
(R) _____________
(L) ___________
d. Neck Vein Distention
__________________________________________________
4. CHEST
a. Anterior Chest
______________________________________________________________
b. Posterior Chest
______________________________________________________________
c. Breasts
1. Breast and Axillae _________________________________________________________
2. Anterior Thorax
________________________________________________________
3. Posterior Thorax ________________________________________________________
5. GASTRO-INTESTINAL
a. Bowel Sounds
______________________________________________________________
b. Tenderness or rigidity ____________________________________________________________
6. URINARY
a. Bladder _______________________________________________________________________
7. SKELETAL
a. Joints ________________________________________________________________________
b. Range of Motion ________________________________________________________________
8. NEURO
a. Motor Function
1. Facial __________________________________________________________________
2. Extremities ______________________________________________________________
b. Sensory Function (equal or not equal) _______________________________________________
c. Equilibrium
1. Balance _________________________________________________________________
2. Finger to Nose ___________________________________________________________
d. Reflexes (equal or not equal)
1. Knees
__________________________________ Arms _______________________
9. CRANIAL NERVE FUNCTION
a. Olfactory nerve: (sensory)
1. Sense of smell (coffee, vanilla, etc.)
1.1 Anosmia _________________________________________________________
1.2 Hyperosmia _______________________________________________________
b. Optic nerve: (sensory)
1. Sense of Vision (Snellens chart, newspaper)
1.1 Myopia __________________________________________________________
1.2 Hyperopia _______________________________________________________

c. Oculomotor: (motor)
1. Extra-ocular movements/Pupil reaction to light
1.1 Right eye________________________ 1.2 Left eye ___________________________
d. Trochlear: (motor)
1. Assess direction of gaze, upward and downward movement of eyeball
______________________________________________________________________________
e. Trigeminal Nerve: (sensory and motor)
1. Presence of corneal reflexes
1.1 Right eye_________________________ 1.2 Left eye ____________________________
2. Ability to clinch teeth _______________________________________________________
f. Abducens (motor)
1. Assess direction of gaze, lateral movements of eyeballs
1.1 Right eye_________________________ 1.2 Left eye ____________________________
g. Facial: (sensory and motor)
1. Sense of taste: Using back tongue
1.1 Salty_______________________________ 1.2 Sweet___________________________
2. Facial expression
2.1 Smile______________________________ 2.2 Puff out cheeks____________________
2.3 Frown_____________________________2.4 Raise lower eyebrows ________________
h. Auditory Nerve: (motor)
1. Sense of hearing
1.1 Right ear_____________________________ 1.2 Left ear_________________________
i. Glossopharyngeal: (sensory and motor)
1. Sense of Taste: Using Back Tongue:
1.1 Sour______________________________ 1.2 Sweet____________________________
2. Ability to swallow (use tongue blade to elicit gag reflex)
______________________________________________________________________________
j. Vagus: (sensory and motor)
1. Hoarseness of Voice ___________________________________________________________
2. Sensation of pharynx ___________________________________________________________
Let the patient say ah and observe (movement of palate and pharynx)
k. Spinal Accessory: (motor)
1. Movement of:
1.1 Head_____________________________ 1.2 Shoulder___________________________
l. Hypoglossal (motor)
1. Able to stick tongue to midline ____________________________________________________
10. EMOTIONAL
a. Communication _________________________________________________________________
b. Mood/Effect ___________________________________________________________________
c. Behavior ______________________________________________________________________
E. Knowledge of Illness
1. Learning Limitations _____________________________________________________________
________________________________________________________________________________
2. Learning Needs ________________________________________________________________
________________________________________________________________________________

F. Nursing Impressions
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
G. Nursing Problems (in priority)
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________
5. ______________________________________________________________________________
H. Discharge Planning
1. Probable Date _________________________________________________________________
2. Destination ____________________________________________________________________
3. Transportation _________________________________________________________________
4. Agencies and Equipment involved __________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5. Diet __________________________________________________________________________
6. Medications ___________________________________________________________________
________________________________________________________________________________
7. Persons responsible for patient ____________________________________________________
8. Family Conference ______________________________________________________________
9. Anticipated Problems ____________________________________________________________
10. Home visit ____________________________________________________________________

Rating Scale
5

When items gives much more than what is expected

when the item gives more than what is expected

when the item gives what is expected

when items gives less than what is expected

when the item gives much less than what is expected

_____________________________________

______________________________

Signature of Student

Signature of Clinical Instructor

(6)