BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
ASSESSMENT TOOLS

I.

DATA BASE AND HISTORY

Name of Patient: ___________________________Date of Birth: ______________ Sex: ______ Age: _______

Address: __________________________________________________________________________________
Religion: _______________________________ Civil Status: _______ Nationality: ______________________
Date of Admission: _______________________ Time of Admission: _________________________________
Informant: ______________________________ Relation to Patient: __________________________________
Address of Informant: _______________________________________________________________________
Initial vital signs:
Temperature: _________ Pulse Rate: ________ Respiratory Rate: _________ Blood Pressure: _____________
Chief Complaints and History of Present Illness:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Has received blood in the past?

Yes _____

No ______

if yes, list dates_________________

Blood reactions if any: ______________________________________________________________________

__________________________________________________________________________________________
Allergies:
Food: ______________________________________________________________________________
Medications: _________________________________________________________________________
Admitting Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Attending Physician: _________________________________________________
Consultant: _________________________________________________________

II. NURSING ASSESSMENT

A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, comfort.
Objective
General Appearance: Alert/responsive
Apathetic Cachexia Abdominal Distention
Mass Tenderness/pain
Skin: Dry Warm Cold Moist Edema
Turgor: ____________________________________
Eyeball:

Sunken

Moist

Dry

Mouth: Dentures Braces Lesions

Cleft Palate Cleft Lip Ulcers
No. of teeth: ______________________
Tongue: Dry
Moist Furrows
Venous filling: ________ (Normal less than 3-5 sec)
Intravenous Fluid: __________________________
Date of insertion: ____________________________
Wounds: __________________________________
Tube/Drainage: _____________________________
Vital Signs: T _____ P ______ R_______BP ______
Body Types:
Ectomorph Mesomorph
Obese
Thin

Endomorph

Subjective
Usual Diet: ___________________________________
No. of meals per day: ___________ (3x a day)
No. of fluid drink each day: _______(8-12 glasses/day)

Alcohol and Beverages ________________________

Undesired Weight loss:
Undesired Weight gain:

Yes
Yes

No
No

Food restrictions R/T intolerance and health

problems or religious practices?
_____________________________________________
_____________________________________________
Difficulty in eating and swallowing:
_____________________________________________
_____________________________________________
Previous/Recent Illness:
Diabetic Hyperthyroidism Hypothyroidism
Colon Cancer Abdominal Pain
Comment: ___________________________________
_____________________________________________
_____________________________________________
Elimination pattern: Diarrhea Constipation
Frequency of BM:______________/day

Loss of Appetite: Anorexia Bulimia

Body weight: _____________kg
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________

B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective
Breath Sounds: Diminished/Absent Stridor
Rales/Crackles Rhonchi/Wheezing
Normal (Vesicular, Bronchovesicular, Bronchial)
None (atelectasis)
Resonance: Hyper Hypo
Respiration/Oxygenation:
Normal(Relax, Effortless and Quiet)
Labored/Use accessory Muscle] Dyspnea
Tachypnea Bradypnea
Cyanosis
Pallor
Cheyne-stoke
Biots
Hyperventilation Hypoventilation
Nasal Flaring
Pursed lip Barrel Chest
Pleuritic Pain
O2 Inhalation _____liters/min
Rate: ________________________
Tube/Drainage: CTT Oral Airway
Endotracheal Tube
Ventilator
Cough:
Productive Non-productive
Sputum: Mucoid
Bloody (hemoptysis)
Rusty Frothy
Thick Tenacious
Color: ____________________________

Subjective
Previous/Recent Illnesses:
Bronchitis
Emphysema
Asthma
Brochiectasis
Pneumonia
Hydrothorax
Pneumothorax Hemothorax
CHF
Chest Trauma
Lung Cancer
Comment: ____________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Breathing Treatments/Medication: ______________
_____________________________________________
_____________________________________________
_____________________________________________
Smoking:
Yes
For how long: __________
No
Comment:____________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________

C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective
Subjective
Temperature: _______________ Celsius
Previous/Recent Illness:
Blood Pressure: Right_______ Left ___________
CVA
CHF
MI
Thrombophlebitis
Family History of HPN Renal Failure
Pulses:
Bleeding Disorder __________________________
Carotid Pulse: Thready Weak Strong Absent
Comment: ____________________________________
Rate: Right______Left______
_____________________________________________
Apical: Regular
Irregular
Rate: ____
_____________________________________________
_____________________________________________
Radial Pulse: Regular Irregular Thready Weak
_____________________________________________
Strong Absent Rate: Right______ Left _______
Dorsalis Pedis: Regular Irregular Thready Weak
Strong Absent Rate: Right_____ Left _____
Posterior Tibia: Regular Irregular Thready Weak
Strong Absent Rate: Right_____ Left _____

Heart Rhythm: Tachycardia

Arrhythmia/ Dysrhythmia

Bradycardia

Jugular Veins Distention:

Positive Negative
Nail bed Color : Pink

Blue

Pale

Capillary Refill: ________ (Normal less than 2 sec)

Edema: Pitting Non Pitting
Location: _____________________________
Varicosities: Yes
No
Location: __________________________________
Calf Tenderness (Homans Sign):
Right
Positive Negative
Left
Positive Negative

Do you experience any of the following:

Chest pain
Arm pain
Leg pain
Joint and Back
Dyspnea
Orthopnea
Cough
Numbness and Tingling
Light headedness Fatigue and weakness
Palpitations
Comment: ___________________________________
_____________________________________________
_____________________________________________
Exercises:
Type: _______________________________________
Frequency: __________________________________
Duration: ____________________________________
Problem experience with usual activity and exercise:
Comment: ____________________________________
_____________________________________________
Factors Affecting Activity Intolerance:
Comment: ____________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
__________________________________________________________________________________________
__________________________________________________________________________________________

D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective
Subjective
Skin: Dry Intact Warm Cold moist Comment : ___________________________________
Turgor:_____________________________________ _____________________________________________
_____________________________________________
Pallor Cyanosis Jaundice Rashes
Acanthosis Nigricans Albinism Erythema _____________________________________________
_____________________________________________
Edema Petechia Itching
Drainage _____________________________________________
Swelling Wound Ecchymosis/hematoma
Decubitus Ulcer
Comment:____________________________________
Temperature: _________
_____________________________________________
_____________________________________________
Hair: Alopecia Hirsutism Patchy hair loss
Distribution: ________________________________ Comment:____________________________________
_____________________________________________
_____________________________________________
Nails: Dirty Pallor
Cyanosis
_____________________________________________
Clubbing
Paronychia Onycholysis
Capillary refill: __________ (Normal less than 2 sec)
Color: _________________
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:

E. ELIMINATION
Objective
Mobility and Dexterity:
Ambulatory Non-ambulatory
Bedridden with assistive device
Tubes/Drainage/Stoma:
Colostomy Ileostomy
NGT
Catheter
Suprapubic Catheter
Abdomen:
Soft
Firm
Distended Non-distended
Bowel Sounds: (5 20 sounds/min)
Normoactive
Hypoactive
Hyperactive(Borborygmi) Absent
Measurement:
Intake ____________ Output:_______________
Edema:
Yes
No
Location: __________________________________
Present Urine Color: ________________________
Note: Assess urine frequency, color, odor control,
comfort/gyn-bleeding, discharge.
Comment: __________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

Subjective
Previous/Recent Surgery/Illness:
_____________________________________________
History of pain and discomfort: _________________
_____________________________________________
Diet: ________________________________________
Personal Elimination Habits:____________________
_____________________________________________
Elimination Problem:
Loose bowel movement _________
Constipation Impaction Fecal Incontinence
Neurologic Impairment Dysuria
Urgency
Polyuria Oliguria
Nocturia Dribbling
Incontinence Hematuria Retention
Discharge
Residual urine (> 100ml)
Comment: ___________________________________
_____________________________________________
Medication taken:
Analgesic Narcotic
Antibiotics Anticholinergic NSAID
Aspirin
H2 antagonist
Fluid intake per day: __________ liters/day
Physical Activity: _____________________________
Comment: ___________________________________
_____________________________________________
Excessive Perspiration and Odor Problem:
Yes No
Consistency:
Stools: ______________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, comfort.
Objective
Subjective
Do you experience any of the following:
Mobility: Ambulatory Non Ambulatory
Lumbar pain Thoracic Pain Cervical Pain
Bedridden
Appliance __________________________ Joint pain
Comment ____________________________________
Gait and Posture: Lordosis Kyphosis
_____________________________________________
Scoliosis
Shaftling Poliomyelitis
_____________________________________________
Amputated Limb ______________________
Club foot (Talipes)
Varus Valgus Equinovarus

Calcanous

Use of Appliance __________________________

Muscle Tone/Strength:
Normal Slight weakness
Average weakness
Poor ROM
Severe Weakness
Paralysis
Atrophy
Hyperatrophy
Spasm
Abnormal Findings:
Impaired ROM Joint swelling ____________
Contractures/Deformities Crepitus
Tingling/Numbness (Carpal Tunnel Syndrome)
Ankylosis Foot Drop Pressure Ulcers
Urinary Elimination changes _________________
Calf Tenderness (Homans Sign):
Right
Positive Negative
Left
Positive Negative
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

Note:
Objective
Subjective
Do you experience any of the following:
LOC: Alert Lethargic Comatose
Blurring Diplopia
Photophobia
Unresponsive
Inflammation Cataract
Orientation: Person Place
Time/Date pain
Glaucoma Headache Unusual Discharges
Pain
Comment: ____________________________________
_____________________________________________

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

III. LABORATORY AND DIAGNOSTIC EXAMINATION

Date
Ordered

Procedure

Result

Significance

IV. NURSING CARE PLAN

DATA
NURSING DX

OBJECTIVES

NURSING INTERVENTIONS

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RATIONALE

EVALUATION

V. DRUG STUDY
Name of Drug Classification
Generic
(brand)

Dose/
Frequency/
Route

Mechanism of
action

Indication

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Contraindication

Side effects

Nursing Precaution

VI. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

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VII. CONCEPT MAPPING

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