Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •

Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
Name: _______________________________________________________ RLE Group/Section: _________ Hospital Area: _______________________

Clinical Instructor: _____________________________________________

INITIAL PATIENT ASSESSMENT

TOTAL OF 50 POINTS
Admission Date: Room: Time:

___AM ___PM

How admitted: • Ambulatory € Wheelchair € Stretcher € Ambulance € Other

Accompanied by: € Family € Friend € Other

VITAL SIGNS ORIENTATION

Temperature: Height Call light/Bed control [ ] Visitation Rules [ ] Bed Locked [ ]

Pulse: Weight (Actual) lbs. Television [ ] Phone [ ]

Respiration: Educational Channels [ ] Bathroom/Emergency light [ ]

BP: Lights [ ] ID Band On [ ]

PERSONAL ESSENTIALS LIST/ TRANSFER INFORMATION

Valuables to safe [ ] No [ ] Yes (list on valuables envelope only) Date/Room Date/Room Date/Room Date/Room
Sent Home [ ]

Essentials at bedside? (check only those that apply)

Rings [ ] Plain yellow metal [ ] Yellow metal with stone

[ ] Plain white metal [ ] White metal with stone

Watch - Describe

Hearing Aid [ ] Left [ ] Right

[ ] Eyeglasses [ ] Contacts [ ] Left [ ] Right

Dentures Full: • Upper • Lower • Partial: • Upper • Lower•

 Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
Other: (Wheelchair, prosthesis, cane, etc.)

Admission Sending RN Sending RN Sending RN

Receiving RN Receiving Receiving RN

RN

ALLERGIES

• No known allergies • Yes

Allergies: Type of Reaction:

HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN NURSING DIAGNOSIS

1. Informant: [ ] Patient [ ] Family Member [ ] Unable to obtain

2. Present Illness/Current/Reason for Hospitalization:

Health Maintenance Altered

Noncompliance (Specify

3. Date last admitted: Never admitted

4. Previous Hospitalization/Surgical Procedures:

Infection, Potential for

Injury, Potential for

5. Medical Diabetes ____ Respiratory Disease_______ Kidney Disease______ Mental Illness _________ Other (Specify)
History: Hypertension ____ Hepatitis _____ Thyroid Disease______ Arthritis ___________
Heart Disease _____ Vision Disorder _____ Neuro-Muscular Disorders ______ STD ___________
Tuberculosis _____ Seizure Disorder: Problems with Anesthesia Other:_______________________________________
 Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105

6. Medications: Including OTC Dugs/Treatment Used at Home

See Emergency Department Medication Review Sheet List Room Below if Patient not seen in Emergency Time Last Dose
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________
__________________________________________________ ____________________________________________ ___________________________

Insulin’s: ____________________________________________ ___________________________

Transdermal:

7. Do you take your medications as ordered? • Yes • No Why? ________________________________________________________________________________________________________________________________________________

8. Disposition of Medications: • Not Brought with Patient • Sent Home with Family • Sent to Pharmacy

9. Use of • Alcohol • Tobacco • Recreational Drugs • Alcohol • Tobacco • Recreational Drugs

How much? ________________________________________________ How long? _________________________________________________________

SYSTEM ASSESSMENT NURSING DIAGNOSIS

Cardio-
• Chest Pain Rhythm • Regular Radial • Palpable Dorsalis • Palpable Edema • Present
Vascular
• Orthopnea • Irregular Pulses: • Non-palpable Pedis: • Non-palpable • Pitting

• Hypertension Type : • Pounding • Other • Other • Non-pitting

• Pacemaker • Thready • Absent

• Apical Pulse • Weak

Respi
• Cough Chest • Symmetrical Breath • Labored Breath • Clear all lobes
ratory
• Productive Appearance: • Asymmetrical Patterned: • Non- labored Sounds: • Equal & Bilateral

• Non-productive • Crackles

• Dyspnea • Rhonchi

• Orthopnea • Wheezes
Cardiopulmonary
**1. Mobility Status: • Ambulatory • Ambulatory with Assist • Bed rest • Transfer with assist • Walker • Activity Intolerance

2. Assistive Devices: • None • Cane • Wheelchair • Crutches • Prosthesis • Pillows # ________ • Airway Clearance Ineffective

• Other : _________________________________________________________________________________ • Breathing Pattern Ineffective

3. Limitations: • None • Weakness • Fatigue • Other _______________________________________ • Decreased Cardiac Output

 Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
_______________________________________________________________________________________
• Activity Intolerance, Potential
4. Do you have enough energy for desired activity? • Yes • No Described: _______________________
• Gas Exchange Impaired
_______________________________________________________________________________________
5. Activities of daily living: I= Independent A= Assist D= Dependent • Home Maintenance
_____ Feeding _____ Bathing _____ Grooming Describe ________________________
_____ Toileting _____ Dressing _____ Other • Management, Impaired

• Physical Mobility, Impaired

• Self Care Deficit, specify:

____________________________
• Other (specify) _____________
Musculo-
**• Pain • Cramping Muscle Strength: (S= Strong W= Weak N= None)
skeletal
• Joint Stiffness • Spasms Grips: • Right • Left

• Swelling • Tremors Pushes: • Right • Left

Neurological
**• Headache Pain Pupil Size • PERL Level of • Alert Oriented to: • Person

• Motor Disturbances • Other Consciousness: • Stuporous • Place

• Seizures Right ____________ • Semi comatose • Time

• Numbness Left ____________ • Comatose • Event

• Tingling • Combative

• Anxious

• Confused

**1. Visual Impairment: • None • Wears eyeglasses 4. Communication: Language/ Barrier • Yes • No • Pain

• Contacts 5. Level of Education: Grade: __________________ • Pain Chronic

• Blind • Right • Left • Communication Impaired

2. Hearing Impairment: • None • Hard Hearing 6. Pain Discomfort: • Verbal

• Deaf _____ Right _____ Left Describe: ________________________________ • Knowledge Deficit ( Specify)
______________________________
• Uses hearing aid _____ Right _____ Left A. Precipitating Factors:
3. Speech Impairment: Describe: ______________________________ • Injury Potential for

• None • Cannot express • Sensory/Perception, Altered (specify) _______________________

• Slurring • Cannot understand B. How is pain controlled? • Thought Processes, Altered

• Mute • Tracheostomy Describe: ________________________________ • Unilateral Neglect

• Stutters • Laryngectomy • Other (Specify) ________________

Integumentary
• Normal Temperature: • Hot Describe: • Decubitus • Bruises
 Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
• Pale • Warm • Rashes • Scars

• Flushed • Cool • Wounds • Not visible

• Cyanotic Turgor : • Good • Lesion • Others

• Jaundice • Fair

• Other • Poor

• Skin Intact*

Nutritional /
1. Special Diet • Yes • No • Body Temperature, Potential Altered
Metabolic
Describe: ________________________________________________________________________________
• Fluid Volume Deficit
2. Frequency of Meals: Describe: ______________________________________________________________
3. Recent Changes in Appetite/ Eating/ Patterns? • Yes • No • Swallowing Impaired
Describe: ________________________________________________________________________________ • Infection Potential For
__________________________________________________________________________________________
• Nutrition: Less than Body Requirements, Altered
4. Have you experienced • Indigestion • Vomiting • Difficulty Chewing • Choking with meals
• Nutrition: More than Body Requirements, Altered
Current/recent • Nausea • Sore Mouth • Difficulty Swallowing • Full Feeling In Throat
Describe: ________________________________________________________________________________ • Oral Mucous Membrane, Altered
5. Recent weight Loss/Gain? • Yes • No • Skin Integrity, Impaired
Describe: ________________________________________________________________________________
• Skin Integrity, Potential Impaired

• Other (specify) __________________

HEALTH PATTERN ASSESSMENT
Gastro Intestinal
General • Well Nourished Oral • Dry Bowel • Present • Ostomies

Appearance: • Malnourished Mucosa • Moist Sounds: • Absent • Gastrostomy

• Obese • Nasogastric

• Jejunostomy

Patients at Risk to Develop Pressure Sores

Identify any patient at risk to develop pressure sores by assessing the seven clinical parameters and assigning a score. Patients with intact skin, but scoring 8 or greater, should have the Nursing Diagnosis “Potential Impairment of Skin Integrity.” Directions: Choose the
number which best describes the patient’s status total the seven numbers.
Clinical Condition Parameters Score Clinical Condition Parameters Score Clinical Condition Parameters Score
General Physical Condition (Health Problem) Mobility (extremities) Skin/Tissue Status
Good (minor) 0 Full active range 0 Good (well nourished skin intact) 0
Fair (major but stable) 1 Limited movement with assistance Fair (poorly nourished skin intact) 1
Poor (Chronic serious but not stable) 2 2 Poor (skin not intact) 2
Move only with assistance 4
Immobile 6

Level of Consciousness (to commands)
Alert (responds readily)
Lethargic (slow to respond)
Semi- comatose( respond only to verbal or
Painful stimuli)
Comatose (no response to stimuli)
Activity
Ambulant without assistance
Ambulant with assistance
Chair fast
Bed fast
Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
Incontinence (bowel and bladder) Nutrition (for age and size)
0 None 0 Good (eats/drinks adequately - ¾ of meal) 0
1 Occasional (less than 2x in 24 hours) 2 Fair (eats/drink inadequately at least ½ of
Usually (more than 2x in 24 hours) 4 meal) 1
2 No control 6 Poor (unable/refuses to eat/drink less than
3 ½ meal) 2
0
2
4
6

Total

HEALTH PATTERNS ASSESSMENT NURSING DIAGNOSIS

GENITO- Description per _____ Nurse _____ Patient
URINARY

Urine Color: • Clear • Hematuria • Bladder distension • Suprapubic Catheter

• Dark • Cloudy • Foley Catheter • Urostomy

• Other • Dialysis Access

ELIMINATION Description per _____ Nurse _____ Patient
• Constipation

• Diarrhea
1. Bowel: • No Problems • Diarrhea • Pain • Blood in stool
• Incontinence, Bowel
• Constipation • Incontinence • Hemorrhoids • Other
Describe: ____________________________________________________________________________ • Incontinence, Functional
2. Bladder: • No Problems • Incontinence • Frequency • Burning • Nocturia • Incontinence, Total
• Retention • Dribbling • Dysuria • Urgency • Other • Urinary Elimination, Altered
Describe: ____________________________________________________________________________
• Urinary Retention
3. Interventions: • None • Laxatives • Suppositories • Enemas • Other
• Other (specify) ________________________________
Describe: ____________________________________________________________________________

REPRODUCTIVE Male
• Penile Discharge • Pain • Inguinal Mass • Penile Implant • Other • Role Performance, Altered

• Tenderness • Scrotal Mass • Breast Lumps • STD (Sexually Transmitted • Sexual Dysfunction
Diseases) • Sexuality Patterns, Altered

Female LMP ____________ Last Pap Smear : __________ Pain With: • Rape Trauma Syndrome
Pregnant:
• Body Image Disturbance
Para ____________ • Itching • Breast Lumps • Menstruation • Yes
 Integrity • Professionalism • Commitment • Competence • Openness • Teamwork •
Patriotism
Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105
Gravida _________ • Abnormal Bleeding • PMS • Intercourse • No • Other ( Specify)

• Contraceptive • Discharge • Other

ROLE
1. Home Environment: • Lives with spouse • Lives Alone • Lives with Family • Lives with friends • Communication Impaired
RELATIONSHIP
• Verbal
2. Who do you rely on for emotional support? • Spouse • Family • Friend • Self • Others • Family Processes, Altered
Describe: __________________________________________________________________________________
• Grieving, Anticipatory

3. How does your illness/hospitalization affect your family/significant others? • Parenting , Altered
Describe: __________________________________________________________________________________
• Social Interaction

• Social Isolation
COPING/ 1. Have you had recent changes in your life (job, move, divorce, death, major surgeries, and recent abuse)?
• Violence, Potential for Self Directed
STRESS
• Yes • No Describe: ______________________________________________________________________ Or directed towards other
2. Do you feel you are dealing successfully with stresses associated with this change?
• Role Performance, Altered
Describe: __________________________________________________________________________________
• Fear

• Other ( Specify) ________________

SLEEP /
1. Sleep : • No problem • Difficulty falling asleep • Difficulty staying asleep • Does not feel rested after sleep • Sleep Pattern Disturbance
REST
Other: _____________________________________________________________________________________
• Other ( Specify) ________________________________
2. What helps you sleep? ________________________________________________________________________
SELF 1. What concerns you most about your illness/hospitalization?
• Anxiety
PERCEPTION Describe: __________________________________________________________________________________
2. Does your illness and/or hospitalization affect your sexuality/body image? • Yes • No • Fear

• Powerlessness

• Self- Esteem Disturbance

• Other (Specify) ________________

1. Is religion important in your life? • Yes • No • Religion/Faith : ___________________________________ • Spiritual Distress

VALUES
BELIEFS 2. Do you have special religious request during this hospitalization? • Yes • No • Notify Volunteer Services • Other (Specify) ________________________________
Describe: ________________________________________________________ for Clergy
SAFETY 1. All areas with ** should be considered FPP.
2. FPP should automatically be instituted for pts who have / are: A. Fallen Previously
B. Confused, disoriented or combative
C. Chemical or Physical Restraints Required