Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES ‘goo, (2 Union ‘Tel 072682,08.63 /ichams,dmmmrswsluc.com NURSING DEPARTMENT one ianme toe ADULT HEALTH ASSESSMENT TOOL Preliminary Information: Patents Intat fge:__Sec:| | Male|_Femele Cvs Stas Occupation lnfomant Relationship of informant to Patent Relgon Date of Examination: Aa ofassonrent Day ofhesptazation: Allergies: Food: Drugs: Others: ve 7. os PR RR ozsat Woigt Heist Presence of Paindlcomfot. [None [-] Ves Intensity score: Location: Radiation: Duration: Onset: CPain ual: (leamping [leu Touring [sharp [] shoeing [1 robbing] ae: Clattered Comfort ‘Aggravated by: [_] movement [tight [“] pressure [—] others: Activity Intolerance: Reloved by: Cleatng [lout envionment (lead Cheat [rest Clothe Cinettetive Coping Cintedcatons iNomphamacotge mam Cloters Cbjecive data: [Tprmacingl-Tguardingatctd ere [leyingl_lwincrana|_lotere: fect of pain toL_lsieep____[lemotons Ceppette___ TD aciviy. ects of pant [nausea vertng [loners a Diagnosis CARE CONCERNS TEAD[_]esyetien [rable soppor hesd mine &wretfocn color Dpvascnon HAIYSCAP: [lalopeda [baldness [linfestatons — [Jatnermaiy EyES: [Jnystagmus [_]strabismus Lens [JOpaque [JGear 1 __R Colorof sclera: Dledena [C[sensory/Perceptual Acuity problems: Fuses corrective ens: ‘Others: ‘Wheratich ARs: [1] discharges: Drain: swetting: Di tinnitus [Jhearing problems: kay mage ‘Nose: [nasal discharges [_Jepistaxis [_Joeclusion [_Hnus tenderness: Others: ty imag MOUTH: Lips: Clintact erected lip color Dots disturbance Mucus membrane: C] moist] ary [sores CTiesons Ci beeding other LD inpaked siaiowtg Dentals: Cidecays______Jusesdentures [chewing problem [] gingivitis others: cose ilonn Clsiasie ‘valowing @uties (others Risk For Injury noareness [-lspeechalffaaty CTump _[_imph nade tendemess Risk tor Aspiration Env Sterne: Wace” CRenesuhC1 Wen nocsetadent Tl onete: [Di atachesapptances/ devices (UG, Tach status: Others, Mesieaton7s Dest: ‘CARE CONCERNS Toe Toreves [ssorewes [Jevepone SEnsony STATE ccsscoe: “ata = Spach: Cl ornare, CTateres (Tockng poet o speech om (Cselectie mutism [J aphasia { [L] txressive Receptive [_] Global) oO seizures Cogpiton: Orientation: tine [-]plce (lperson [seit Cibatitun Memon: [limmeciate [_lrecent |] remate Dlaspiraton Pupils: size: reaction: deviation: 7, Canin Nerves Figs. CD Language Swatowing_ normal _ | Taysphaga letter ibeerssie A eas Cag oe deem atte Seiares: No. Ces Tipe: Ovation Incontinence .= SO:eve ofijune—_ leomplte [Tincomplete enzo ignttoucn ppd C sensory Analsensation bladder sensation Elbows: Newrs extensors Thought Process, Fingers: flexors abductors __; hip lexors _;knee extensors; ankle: dorsifexors__|[] tactile i g Plantarfleyors ___; long toe extensors _ discrimination or others: ]rerudsnsk) C]+terigs (Treacache: vertigo Clsyncope ae crimination iMedieatonfs Stereogenesis Graphesthesia Danes Prepared by: Rose Ann R. Tan, RN ‘Ax. 2010-2020‘Mobitty: [_Jhemiplegia__[_Javadriplegia | paraplegia [_] paresis. ‘Muscles: Clspastic Ciflaccid Cltremors C1 tics C1 spasms Cl pain Posturing: {_] kyphosis (] lordosis [—] scoliosis (] decorticate{_] decerebrate [] opis- ‘thotones others Funesional sbi: (lteeding,[]tetting—]transter]cressing [others ‘Supports: [Jeast:_____ stings) traction: others: Medication(s: Dx Result RESPIRATORY Diagnosis: ‘Chest Shape! Llseformities Aythm: [7] regular[Jireguiar (5). Depth:(_Jromal [shatiow []deep [-] mouthbreathing ‘Qvalty: []nonmal [_Jiabored [-Istridor [Jegophony Expansion: C]symmetrical asymmetrical [paradoxical faring [etractions Clsccesory muscies Dyspnea: [-Jabsent [Jat Rest [Jwith Acti [-)S08 [Jorthopnea ‘yanosis: EJabsent central peripheral Tleanvascomior LwxGsouNns: Chest Tubes (loc/charac/status): ‘Muscle Mass: [Jadequate [Jemaciated [—] atrophy others Assistance Needed: [Jnone [Ipartial ["]fullasstve device: Joints: ROM: [—Itull limited Credness: Cl edema: Ostitiness: Ci arthritis Z) tophi: Cldeformities: 1 amputations Cleontractures: Diteot drop coordination: impaired slowed Galt: v ‘cough: [Jabsent [ary harsh [Jproductie [Jnon-productive [] hemoptysis | Absent (secretions color/amt: Lniahtsweits Gear Normal) -Decresses Fremitus: [present [absent be GF cracks fine) oygentherapy: va____tpm__ Ce races (coarse) Mechventllator: type: setting: made: LUNG PEHERIEESON Attic airway: CET CJNT CVT others Resonant Medicaton/s Hyper resonant Fit Dx Result 1 -Dul POSTERIOR: ichest pain _patptations rails color [Llewbbing captor re seconds ‘Avical Puse: rate: __ [regular [Jiregular PulseDetct: JN [-]¥es PME ‘Abnormalities: murmurs Ditnaits Cleat heaves: loyramicprecordiem [jperceril friction [others Lavo: mess. ‘Auscutatory areas: Aortic: Pulmenic: Tricuspid Nite os os Cardiac Monitor Iyes[_]no Pacemaker: [Jno[-lyes ythm: [_Jregulor[Jireaular. Pulses: Radial__L__R Femoral_t_ Pedal_t__R Edema: [pedal UR[-Jankle UR [-}lowerleg UR [face [-Jnorpltng [~]pttng Grade: Type of Une: [Jena ac Lierioherattoc. TIN inhtrotion har Flovleokage —cvP level: Elvaricostes ifistu/shunts: oc Hema: [Jbnusing:_petechise echymosis ___ purpura hematoma et treorer: No. of units: [reactions crs: insulln ype: vals Others: Medicaon/s Dx Result: Crate [] Decreased ADL's [Sensory Deficit [oDisuse Syndrome: sP: Ci impaired Bed Mobility Ooters: ‘CARE CONCERNS: Dairway clearance [168s exchange [Dacuay Potential Infection [TissuePertusion (lathes [petivity ntoterance Eilmpaires comfort Dleeraae output [tissue Pertusion [Diskin integrity others: an Yan ‘Ax. 2010-2020Grandeur CARE CONCERNS FO TINE tuneh( 100% 75% C)sox C)2s% Cox) others Dioner] 100% EF] 7% som (1) 25% Clos) others: Mt Ti .LPen pe ve tolerated: (ves Fo) Enteral tube type:[_] Not") gastronomy [7] jelunostomy [] others Insertion date NGtube sueton: [Jtow Lleravty Chtteartourn C)anoresia C]nausea [Jemesis (describe) ‘Bowel Sounds; []normoactve []hypoactve []hwperectve Cebsent andomen: [Tso CJtender( Term Cldscendes Clr Clympante Daun Dlascites Clncidwaves Cloruite. Abdominal girth isc hin wihrato: owe! Activity: [] norma regularity: Last BM: Feces! color. amouncive raracteratie Doiarrtes Cconstinated (No. of Days), Limeens Clhemertcigs Comers user: [tenderness [Jenlorgement Clement kidneys: [Jflank pain BUN, BONG ered Neardol Ta yw Sli SC Teain ete andl Losmuris hematuria Clothers: rin: characte: output: (73) @19__ a7). ids too Mass Location): characters: Dias: Clemo Certoneat Cie restriion rasy catreter: Clrotey Clsupraputic CIcondom I rertoneat Clan rit Bowel Diversion: (Char/Ste Urinary Diversion: (nar Cleat: pe of soution rinse! Macicstions Screening Methods: []colonoscopy (Jsigmoidoscopy [] barium Enema [_]barium sw. ["]Fo8T Lestat parformes: esate ab resus] Our Oasvatr. Datoumin. other Dxresut surgeries Masiestions REPRODUCTIVE SYSTEM | Diagnosis: FEMALE ‘Menses: [J regular Cl irregular Amenorrhea: Clprimary Ll2ndary [=] Menopausal [] Heavy Flow [-]Dysmenormhea No.of Pads used during menstruation: Characteristics of menses/discharge: Breast (éraw abnormalities here) Breast: symmetry discoloration: Oi tenderness Dasimpsing: Di nedutes: Dnippte discharge surgically absent External Genital: [-]Bcorations [ JRash Di tesions. Ovesiess Clinnammation Oi discharge char male tum char restcular chao Testes Doescended Clundescended Doisoaces mestus Hyoosrata/ Espasa) rectle Dstuncion-{_les [_No [pias [Lpenie biseharge: Char ([Goberniae __umbitcal inguinal Screening Methods: L]ase Cicae Ci Mammography others: Clrap Smear (ast pap smear), CNutition Dhspiraton Cswationing (rue Cicenstipation Coiarthea Ctowe! Elimination Dlurinary Elimination castro: intestinal motity Ciskin integrity Cloters: ‘CARE CONCERNS: Bisexual Patterns Ciknowledge Deficit Dlothers: Ress lphimosi Cnvaracele []vatcocele Bother reening Metods-[_JT3E DRE LSA here A Family earning Use: [TNO L-1Yes [Natu Tania: since Wher: Medications De Rests: Surges: Prepared by: Rose Ann R. Tan, RN ‘AN.2010-2020Turgor eee SS ee oc Characteristics; Cldry Clmoist Cloity Cidiaphoresis Color: [pate[}eyanotic [flushed [jaundiced] mottled Temperature Ctesions type: locfehar wounds (type): océchar, Cloves (ye: locfehar; Creer BE wim BE wife BE opt! W'S! AX® Couns: 9% Degree: implants Mesicatio Tet N OM BA NSM BA NOM Be PSYCHOSOCIAL ASSESSMENT [FevenosesiALassesewenr [ssp [ean concerns ed ody image ‘Aids and augmentation: Development: stage, tasks and concems: [frickso, ‘Expectations and Concerns about hospitalization: Effects of hospitalization: [_] sel work: Clramity soda tite: teaming Needs: Mood: [] depressed Clespansive Clinitatie Clkuphorie Cinood wings Chthers Affect: apathy [tat CIblunted Crestrcted Clabie Clothers Thought: [_Jeontent process Fitton, Perception: [—] delusion ‘Dhatucination. Dittusien. Doothers, Motor: [Thypoactive CJnyperective Clethers ‘oTHers: Clmeod swings Llambivalence Behavior: Appropriate tosituation? Clves []wo, describe Sleep: [| aiticuttyfalingasleep [Jnot restedatter sleep [_Jaidsto sleep reels Communication pattern: [Inon-verbal_ (“] verbal Spacty, ‘stress-coping pattern? Sourcas of stress: ways of coping: ‘Avaliabilty of Suppo? Source: adequacy Rolerelationship pattern: (Describe role, Interacon pattem and concerns) Family 8. Work © Cornerunity| Seauaity and Sexual Concerns? Sex Preference Disenual Problem(s: aids toSexPerormance Dotter soca story: 1 tes alone lives wth amtalttin ( Vereh race Diet Meee A Marois C Atcoho use; Amount: For how long? C1 eete nut crewing ength of uses (Cl secalarue Typer frequency? Financial concerns (describe) Housing concerns: Legal concems: cultura religious practice important to cent during hospitalization? Any advance directives? [-] Yes, specity Other Concerns No CINo need for more information INTEGUWENTARY svsreM | Downes CARE CONCERS | Skin integrity Ci Themme- regulatory statis Risk for itntecton Clothers: ‘CARE CONCERNS: Ded image Disettesteem thought aeration Dorerceptual Datteration Ofear Dlamiety Clpowertessness Ditopetessness, Dsieep pattern Disturbance Diinettective coping Ciimpaires LD adustment Cramty Nees Ditssuepertusion (CParenting Needs Dspirtustneeds Deutrai needs Dsuicd risk Drove conti Dsedness Depression Dorner: | do hereby certify that all information written on this assessment tool are true and correct. Signature over Printed Name Date: Name of Hospital: ‘Prepared by: Rose Ann R. Tan, RN ‘Ax. 2010-2020