ANTROPOMETIC MEASUREMENT

1. Height in
cm
2. Weight
in kg
3. BMI

GENERAL SURVEY

INTERPRETATION/
BODY PART EXAMINED ACTUAL FINDINGS NORMAL FINDINGS
ANALYSIS

4. Level of Consciousness

5. Signs of Distress

6. Body built (height weight in

relation to age and lifestyle)

7. Skin color and Obvious

lesions

8. Dress, grooming, hygiene

9. Body and breath odor

10. Facial expression

11. Posture, gait, motor activity

VITAL SIGNS

BLOOD RESPIRATORY O2
PX INITIALS PULSE RATE TEMPERATURE
PRESSURE RATE SATURATION
 SGA CRISIS NORMAL/ MILD MODERATE SEVERE
Weight loss o Normal o <10% usual wt. o >10% of usual
Food intake o No change o Suboptimal o Starvation
(last 1-2 months)
Gastro symptoms o None o Nausea/ Vomiting o Anorexia,
>2 weeks Diarrhea, Severe
Functional capacity o No change o Dysfunction o Bedridden 2 wks
<3wks,
Suboptimal work,
Bedridden < 2 wks
Disease and relation o No or low stress o Moderate stress o Severe stress
to Nutritional
requirements
Physical Examination 0 +1 to +2 +3
o Subcutaneous fat o Subcutaneous fat o Subcutaneous fat
and/or muscle and/or muscle and/or muscle loss
loss loss
SGA Grade A 0 ______ B 1 ______ C 2 ______

NUTRITIONAL ASSESSMENT
NUTRITIONAL CHART
BMI 18.5- 25 0 _____ 25.1- 30 1 _____ < 18.5 or >30 2 _____
Serum albumin (g/dL) > 3.4 0 _____ 2.5-3.4 1 _____ <2.5 2 _____
TLC > 1500 0 _____ 900 < 1500 1 _____ <900 2 _____
* No fasting required for serum albumin administration

TOTAL SCORE: ________

0-1 ____________ LOW RISK (LEVEL 1)

2-3 ____________ MODERATE RISK (LEVEL 2)
4+ ____________ HIGH RISK (LEVEL 3)
 Injuries Assessment Section
Beginning with any pressure injuries, number all integumentary issues consecutively, starting with #1, #2, #3, etc. (Skin, Hair and Nails)

Skin Issues
Specify all types below as numbered / designated above: The number, skin issue type and comments.
Examples of possible types of skin issues from CARE include pressure injuries, abrasions, acne / persistent redness, boils, bruises,
burns, canker sore, diabetic ulcer, dry skin, hives, open lesions, rashes, skin desensitized to pain / pressure, skin folds / perineal rash,
skin growths / moles, stasis ulcers, sun sensitivity, and surgical wounds. Please note there are many other skin issues not mentioned
here such as irregular skin area such as boggy or mushy skin area, discoloration area(s).
Please note: Any current pressure injuries require further detailed documentation on Pressure Ulcer Assessment and Documentation,
form DSHS 13-783.
COMMENTS (PROVIDE FURTHER (NON-PRESSURE INJURY) DOCUMENATION IN
NUMBER SKIN ISSUE TYPE AND LOCATION ADDITIONAL NOTES SECTION. FURTHER PRESSURE INJURY DOCUMENTATION
REQUIRES FORM DSHS 13-783.)

SKIN ASSESSMENT:
 Basic Skin Assessment – Additional Detail (Check – Off and Notes)
CONSIDER HISTORY OF SKIN CONDITION
• How long has the condition been present? • Any habits, behaviors or hobbies or other affecting the skin?
• How often does it occur or recur? • What medication is client taking?
• Are there any seasonal variations? • Any known allergies?
• Is there a family history of skin disease? • Include previous and present treatments and their effectiveness.

Color: Pale WNL Cyanotic Jaundice Other (describe):

Notes:

Temperature: Afebrile Warmer than normal (febrile) Other (describe):

Notes:
Turgor: Normal Slow (tenting)
Notes:
Any foul odor: Yes No
Notes:

Moisture: WNL Dry Diaphoretic Other (describe):

Notes:
Skin integrity: WNL / intact See problem list
Notes:
Moles: Present
a. Asymmetry Yes No
b. Border Regular Irregular
c. Color
d. Diameter
Notes: Referral and follow-up for suspect / abnormal or irregular mole:

Hair: Even distributed Hair loss Other (describe):

Notes:

Nails: WNL Thickened Clubbing Discolored Other (describe):

Cap Refill: < 3 sec > 3 sec
Notes:
Non-injury recommendations to CM / CRM (for follow-up with HCP, treatment, care planning, or other directions):