ST.

ANTHONY COLLEGE
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: _________________________________________________________
1

PHYSICAL EXAMINATION
GENERAL
APPEARANCE:
TEM
P:

VITAL SIGNS: BP

HEAD
EYE

NORMOCEPHALIC
PERRLA
SQUINT
ANICTERI
C
ICTERIC

EAR
HEARI
NG

PLIABLE

NOSE
MOUTH

PATENT
MOIST

NORMAL

UVULA/ TONSIL
MOVABL
NECK
E
TORSO
BREAS
T
HEART

C
R:

PR
:

RR:

UNEVE
FLAT
N
EXOPTHALMUS
PALE

HARD CARTILAGENOUS

UNEVE
N

UNEVEN
OCCLUD
ED
DRY

SPECIFY

DEAF

PINK

INFLAMMED

PURULE
NT

EXUDATE
S

CLAD
KYPHOS
IS

MASS
LORDOS
IS
ABSCES
S

UNABLE TO SMELL
PINKISH
PALE

SYMMETRIC
AL

ASSYMETRI
CAL

NODULE
S
STRAIGH
T

SYMMETRIC
AL

ASSYMETRI
CAL

INFLAMMED

MASS

NRRR

MURMU
R
WHEEZE
S
RIGID

RHONCI
SOFT

STIFF

LUNGS
BRONCHO VESICULAR
ABDOMEN
FLAT
GENITA
L
NORMAL
RECTUM/ANUS
NORMAL

HERNIA
HEMORRHOI
DS

MASS
FISTULA
3

ABSCES
S
SCOLIOS
IS

FRICTION
RUB

RALES

TENDER
ABSCES
S
MASS

ADENOPAT
HY

ABSCES

S
EXTREMITY UPPER
EXTREMITY
LOWER

SYMMETRIC
AL
SYMMETRIC
AL

ASSYMETRI
CAL
ASSYMETRI
CAL

MOVAB
LE
MOVAB
LE

IMMOBI
LE
IMMOBI
LE

II. NURSING ASSESSMENT

A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, and 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: ____________________________

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
Tube/Drainage: _____________________________ Colon Cancer Abdominal Pain
Comment: ___________________________________
Vital Signs: T _____ P ______ R_______BP ______ _____________________________________________
_____________________________________________
Wounds: __________________________________

Body Types:
Ectomorph Mesomorph
Obese
Thin

Endomorph

Elimination pattern: Diarrhea Constipation

Frequency of BM:______________/day

Loss of Appetite: Anorexia Bulimia

Body weight: _____________kg
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis:
_________________________________________________________________________________________
_
5

B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective
Subjective
Breath Sounds: Diminished/Absent Stridor Previous/Recent Illnesses:
Bronchitis
Emphysema
Asthma
Rales/Crackles Rhonchi/Wheezing
Pneumonia
Hydrothorax
Normal (Vesicular, Bronchovesicular, Bronchial) Brochiectasis
Pneumothorax Hemothorax
CHF
None (atelectasis)
Chest Trauma
Lung Cancer
Comment: ____________________________________
Resonance: Hyper Hypo
_____________________________________________
_____________________________________________
Respiration/Oxygenation:
_____________________________________________
Normal(Relax, Effortless and Quiet)
Labored/Use accessory Muscle] Dyspnea
Tachypnea Bradypnea
Cyanosis
Breathing Treatments/Medication: ______________
Pallor
Cheyne-stoke
Biots
_____________________________________________
Hyperventilation Hypoventilation
_____________________________________________
Nasal Flaring
Pursed lip Barrel Chest _____________________________________________
Pleuritic Pain
Smoking:
O2 Inhalation _____liters/min
Yes
For how long: __________
Rate: ________________________
No
Tube/Drainage: CTT Oral Airway
Comment:____________________________________
Endotracheal Tube
Ventilator
_____________________________________________
_____________________________________________
Cough:
Productive Non-productive
_____________________________________________
Sputum: Mucoid
Bloody (hemoptysis)
_____________________________________________
Rusty Frothy
Thick Tenacious
Color: ____________________________

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: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7

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: ______________________________________
9

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__
F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, 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

Comment: ___________________________________
_____________________________________________

Use of Appliance __________________________ Comment: ___________________________________

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 _________________

_____________________________________________
Comment: ___________________________________
____________________________________________
_____________________________________________
_____________________________________________

Comment: ___________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Calf Tenderness (Homans Sign):

Right
Positive Negative
Left
Positive Negative
Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
10

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC
Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,
Objective
Subjective
Check the Following Risk Factors:
LOC: Alert Lethargic Comatose
Older Adulthood Male
Hx Stroke or TIA
Unresponsive Obtunded Stupor
Hypertension
Smoking
Hx CVD
Decorticate
Decerebrate
Sleep Apnea
High level of Cholesterol
GCS Score: _________
Drug Abused
DM
Oral Contraceptives
Menopausal
Over weight
Cushing Triad (Respiratory changes, Increase BP,
Comment: ____________________________________
Decreasing level of Consciousness)
Positive
Negative
Do you experience any of the following:
Sensation: Positive

Negative

Pupillary Size: PERRLA Anisocoric

Orientation: Person
Pain

Place

Time/Date

Blurring Diplopia
Photophobia
pain
Inflammation Cataract
Glaucoma Headache Unusual Discharges
Comment: ____________________________________
_____________________________________________

Sensory Function: Positive Negative

Location: __________________________________
Motor Function: Positive Negative
Location: __________________________________
Vital Signs: BP: ______ T______P_____R______
Brudzinskis sign: Positive Negative
Kernigs Sign:
Positive Negative
Reflexes:
Patellar
Biceps
Triceps
Achilles

Positive Negative
Positive Negative
Positive Negative
Positive Negative
11

Remarks: _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nursing Diagnosis: _________________________________________________________________________
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_
_________________________________________________________________________________________
_

III. LABORATORY AND DIAGNOSTIC EXAMINATION

Date
Ordered

LABORATORY AND
DIAGNOSTIC

Result

Significance

12

13

IV. NURSING CARE PLAN

DATA

NURSING DX

OBJECTIVES

NURSING INTERVENTIONS

14

RATIONALE

EVALUATION

V. DRUG STUDY
Name of Drug
Generic
(brand)

Classification

Dose/
Frequency/
Route

Mechanism of
action

Indication

15

Contraindication

Side effects

Nursing Precaution

VI. SOAPIE (First day)

16

VI. SOAPIE (Second day)

17

VI. SOAPIE (Third day)

18

VII. HEALTH TEACHINGS

Medications:

Exercise:

Treatment:

Out patient (Check up)

Diet:

19

VII. PATHOPHYSIOLOGY
Name of Patient: __________________________________ Age: ______________ Sex _________________
Diagnosis: ________________________________________________________________________________
Definition:

Reference:

20