ADULT MEDICAL/SURGICAL ASSESSMENT TOOL

( Adapted from Nursing Care Plans Guidelines for Across the Life Span
Client Doenges, Moorhouse, Murr : 2010)
General Information
Name: Rosalie Torres
Age: 34
DOB: 07/29/1981
Gender: Female Race: Filipino
Admission Date: ___________________ Time: __________________ From: ZCMC
Reason for this visit (primary concern): Case presentation on the Nursing faculty in Pilar College
Cultural concerns (relating to healthcare decisions, religious concerns, pain, childbirth, family involvement,
communication, etc.):
__________________________________________________________________________________________
_______________________
Source of information: Mother
Relaibility (1-4 with 4 = very reliable): 2
Activity/Rest
Subjective (Reports)
Occupation: SPED student
Able to participate in usual activities/hobbies: Dancing, Zumba
Ambulatory: Yes Gait (describe): Yes, active
Activity level (sedentary to very active): Active
Daily exercise/type: Zumba
Muscle mass/tone/strength (e.g. normal,
increased, decreased): normal
History of problems/limitations imposed condition
(e.g. immobility, cant transfer, weakness,
breathlessness): ______________________________
Feelings (e.g. exhaustion, restlessness, cant concentrate,
dissatisfaction): ______________________________
Developmental factors (e.g. delayed/age): ___________
Sleep: Hours: __8hrs______ Naps: ___2times________________
Insomnia: __________ Related to: _____________
Difficulty falling asleep: _____________________
Rested on awakening: _______________________
Excessive grogginess: _______________________
Bedtime rituals: _______________________________
Relaxation techniques:__________________________
Sleeps on more than one pillow: __________________
Oxygen use (type): _______ When used: ___________
Medications or herbals for/affecting sleep: _________
__________________________________________
Circulation
Subjective (Reports)

Objective (Exhibits)
Observed response to activity: Heart rate: 84
Rhythm (reg/rreg): Lub Dub
Blood pressure: 140/90
Respiration rate: 20 per minute
Pulse oximetry: 99% room air
Mental status (i.e., cognitive impairment,
withdrawn/lethargic): cognitive impairment
Muscle mass/tone: 40%muscle 60%body fat
Posture (e.g. normal, stooped, curved spine): normal
Tremors: none
(location) :
ROM: normal
Strength: can perfume on herself without assistance and without pain
Deformity: none
Uses mobility aid (list): none

Objective (Exhibits)

History of treatment for (date): High blood pressure: ____

Color (e.g. pale, cyanotic, jaundiced, mottled, ruddy): pinkish conjunctiva
Brain injury: __none_______ Stroke: ___none________
Skin: _normal turgor Mucous membranes: _normal___ Lips: slightly pale________
Heart problems/surgery: __none______ Palpitations: _none______
Nail beds: _normal______ Conjunctiva: slightly pale Sclera: non icteric
Syncope: ____ Cough/hemoptysis: ____ Blood clots: _none__ Skin moisture (e.g. dry, diaphoretic): dry
Bleeding tendencies/episodes: __none___________________ BP: Lying: R _______ L __________ Sitting: R: _________ L _____________
Pain in legs w/ activity ___none______________
Standing: R _________ L ____________
Extremities: Numbness: ___none_______ (location): _none________
Pulse pressure: __________ Auscultatory gap: _______________________

Tingling: _none_______ (location): ___none__________________

Pulses (palpated 1-4 strength): Carotid: _________ Temporal: ______________
Slow healing (describe): ___none_________________________
Jugular: ______ Radial:_________ Femoral: _________ Popliteal: _________
Change in frequency/amount of urine: _________________
Post-tibial: _______________ Dorsalis pedis: __________________________
History of spinal cord injury/dysreflexia episodes: _none_______ Cardiac (palpitation): Thrill: __________ Heaves: ________________________
Medications/herbals: _______________________________
Heart sounds (auscultation): Rate: ___________ Rhythm: __________________
Quality: _______________ Friction rub: _______
Murmur (describe location/sounds): _________________________________
Vascular Bruit (location): ___________________________________________
Breath sounds (location/describe):_____________________________________
Extremities: Temperature: __________ Color: ___________________________
Capillary Refill (1-3 sec): ________ Homans sign: ____________________
Varicosities (location): ___________________________________________
Edema (location/severity +1 - +4): ____________________________________
Distribution/quality of hair:________________________________________
Trophic skin changes: ___________ Nail abnormalities: ________________

Ego Integrity
Subjective (Reports)
Relationship status:______________________________________________
Expression of concerns (e.g. financial, lifestyle
or role changes: _________________________________________________
Stress factors: ___________________________________________________
\Usual ways of handling stress: _____________________________________
Expression of feelings: Anger: _____________ Anxiety: ________________
Fear: _____________ Grief: _______________ Helplessness: ____________
Hopelessness: _____________ Powerlessness: _________________________
Cultural factors/ethnic ties: ________________________________________
Religious affiliations: ________________ Active/practicing: _____________
Practices prayer/meditation: ______________________________________
Religious/spiritual concerns: _____________________________________
Desires clergy visit: ____________________________________________
Expression of sense of connectedness/harmony
With self and others: ___________________________________________
Medication/herbals: ______________________________________________
Elimination
Subjective (Reports)
Usual bowel elimination pattern: ____________________________________
Character of stool (e.g. hard, soft, liquid) ___________________________
Stool color (e.g. brown, black, yellow,
Clay colored, tarry) ___________________________________________
Date of last BM and character of stool: _______________________________
History of bleeding: ___________ Hemorrhoids/fistula: _________________
Constipation: acute: ___________ or chronic: _________________________
Diarrhea; acute: ___________ or chronic: _________________________
Bowel incontinence: ___________________________________________
Laxative: __________ (how often): _________________________________
Enema/suppository: _______ (how often): _________________________
Usual voiding pattern and character of urine: _________________________
Difficulty voiding: ___________ Urgency: __________________________
Frequency: ________________ Retention: ________________________
Bladder spasms: ____________ Burning: _________________________
Urinary incontinence (type/time of day usually occurs): ________________
History of kidney/bladder disease: _________________________________
Diuretic use: _________________ Herbals: __________________________
Food/Fluid
Subjective (Reports)
Usual diet (type): _______________________________________________
Calorie, carbohydrate, protein, fat intake (g/day): ____________________
# of meals daily: ________ Snacks (number/time consumed): _____________
Dietary pattern/content:

B: ___________________________________________________________
L: ___________________________________________________________
D: ___________________________________________________________
Snacks: _______________________________________________________
Last meal consumed/content: ______________________________________
Food preferences: ________________________________________________
Food allergies/intolerances: ________________________________________
Cultural or religious food preparation
Concerns/prohibitions: _________________________________________
Usual appetite: ______________ Change in appetite: ___________________
Usual weight: _____________
Unexpected/undesired weight loss or gain: _________________________
Nausea/vomiting: __________ (related to): ___________________________
Heartburn/indigestion: _________________________________________
(related to): __________________ (relieved by): ____________________
Chewing/swallowing problems: ____________________________________
Gag/swallow reflex present: _____________________________________
Objective (Exhibits)
Emotional status (check those that apply):
Calm: _______________________ Anxious: ________________________
Angry: ______________________ Withdrawn: ______________________
Fearful: ______________________ Irritable: _________________________
Restive: ______________________ Euphoric: ________________________
Observed body language: _________________________________________
Observed physiological responses (e.g. palpitations, crying, change in voice
quality/volume): ________________________________________________
Changes in energy field:
Temperature: _________________________________________________
Color: ______________________________________________________
Distribution: _________________________________________________
Movement: __________________________________________________
Sounds: _____________________________________________________

Objective (Exhibits)
Abdomen (auscultation): Bowel sounds (location/type): _________________
Abdomen (palpation): Soft/firm: ____________________________________
Tenderness/pain (quadrant location): _______________________________
Distention: _____________ Palpable mass/location: __________________
Size/girth: ______________CVA tenderness:__ _____________________
Bladder palpable: __________ Overflow voiding: ______________________
Rectal sphincter tone (describe): ____________________________________
Hemorrhoids/fistulas: ______________ Stool in rectum: ________________
Impaction: _________________ Occult blood (+ or -) ______________

Presence/use of catheter or continence devices: ________________________

Ostomy appliances (describe appliance and location: ____________________
______________________________________________________________

Objective (Exhibits)
Current weight: _______ Height: __________________________________
Body build: _________ Body fat %: _____________________________
Skin turgor (e.g. firm, supple, dehydrated): ___________________________
Mucous membranes (moist/dry): ___________________________________
Edema: Generalized: _____________________________________________
Dependent: __________________________________________________
Feet/ankles: _________________________________________________
Periorbitals: _________________________________________________
Abdominal/ascites: _____________________________________________
Jugular vein distention: __________________________________________
Breath sounds (auscultate)/location: _________________________________
Faint/distant: ____________ Crackles: ___________ Wheezes: _________
Condition of teeth/gums: ______ Appearance of tongue: _________________
Mucous membranes: _____________________________________________
Abdomen: Bowel sounds (quadrant location/type): _____________________
Hernia/masses: _________________________________________________
Urine S/A or Chemstix: ___________________________________________
Blood glucose (Glucometer): _____________________________________

Food/Fluid (continued)
Subjective (Reports)
Facial injury/surgery: ______________________________________
Stroke/other neurological deficit: __________________________
Teeth: Normal: __________ Dentures (full/partial): _____________
Loose/absent teeth/poor dental care: ________________________
Sore mouth/gums: ______________________________________
Diabetes: _________ Controlled with diet/pills/insulin: __________
Vitamin/food supplements: ________________________________
Medication/herbals: ______________________________________
Hygiene
Subjective (Reports)
Ability to carry out activities of daily living: __________________
Independent/dependent (level 1 = no assistance needed to level 4 =
completely dependent): ___________________________________
Mobility: ________ Assistance needed (describe): _____________
Assistance provided by: ________________________________
Equipment/prosthetic devices required: ____________________
Feeding: _________ Help with food preparation: ______________
Help with eating utensils: ______________________________
Hygiene: ____ Get supplies: ____ Wash body/body parts: ______
Regulate bath water temperature: _____ Get in/out alone: _____
Preferred time of personal care/bath: _____________________
Dressing: ______ Can select clothing: _____ Can dress self: _____
Needs assistance with (describe): _________________________
Toileting: ________ Can get to toilet/commode alone: _________
Needs assistance with (describe): ________________________
Neurosensory
Subjective (Reports)

History of brain injury, trauma, stroke (residual effects): __________

Fainting spells/dizziness: __________________________________
Headaches (location/type/frequency): ________________________
Tingling/numbness/weakness (location): ______________________
Seizures: _______ History or new onset seizures: _______________
Type (e.g. grandma, partial): ______ Frequency: ______________
Aura: _______ Postictal state: ________ How controlled: _______
Vision: Loss/changes in vision: ________ Date last exam: _________
Glaucoma: _____ Cataract: ______ Eye surgery (type/date):______
Hearing loss: ______ Sudden or gradual: _______________________
Date of last exam: _______________________________________
Sense of smell (changes): ___________________________________
Sense of taste (changes): __________________ Epistaxis: _________
Other: ___________________________________________________

Pain/Discomfort
Subjective (Reports)
Primary focus: ___________________ Location: _________________
Intensity (use pain scale or pictures): ___________________________
Quality (e.g. stabbing, aching, burning): _______________________
Radiation: ______ Duration: _______ Frequency: ______________
Precipitating factors: _______________________________________
Relieving factors (including nonpharmaceuticals/therapies):
________________________________________________________
Associated symptoms (e.g. nausea, sleep problems, crying): ________
________________________________________________________
Effect on daily activities: __________________________________
Relationships: _________________ Job: _____________________
Enjoyment of life: _______________________________________
Additional pain focus (describe): ____________________________
Medications: _____________ Herbals: _______________________

Objective (Exhibits)
General appearance: Manner of dress: ______________________________
Grooming/personal habits: ______________________________________
Condition of hair/scalp: ________________________________________
Body odor: __________________________________________________
Presence of vermin (e.g. lice, scabies): ______________________________

Objective (Exhibits)

Mental status (note duration of change): _____________________________

Oriented/disoriented: Time: ____________ Place: ___________________
Person: _____________________________________________________
Situation: ____________________________________________________
Check all that apply: Alert: ______ Drowsy: ________ Lethargic: _________
Stupor: ___ Comatose: ____ Cooperative: _____ Agitated/Restlessness: ___
Combative: ______ Follows commands: ___________________________
Delusions (describe): __________ Hallucinations (describe): _____________
Affect (describe): __________ Speech Pattern: ________________________
Memory: Recent: _________ Remote: _______________________________
Pupil Shape: _________ Size/reaction: R/L:___________________________
Facial droop: ___________________________________________________
Hand grasp/release: R: _____________ L: ___________________________
Coordination: _____________ Balance: __________ Walking: ___________
Deep tendon reflexes (present/absent/location): ________________________
Tremors: __________ Paralysis (R/L): ___________ Posturing: ___________
Wears glasses: __________ Contacts: ___________ Hearing aids: _________
Objective (Exhibits)
Facial grimacing: _______ Guarding affected area: _____________________
Emotional response (e.g. crying, withdrawal, anger): ___________________
Narrowed focus: ________________________________________________
Vital signs changes (acute pain):
BP: _______________________________________
Pulse: _______________________________________
Respirations: __________________________________

Respiration
Subjective (Reports)
Dyspnea/related to: _____________________________________
Precipitating factors: __________________________________
Relieving factors: _____________________________________
Airway clearance (e.g. spontaneous/device): _________________
Cough (e.g. hard, persistent, croupy): _______________________
Produces sputum (describe color/character): _________________
Requires suctioning: ____________________________________
History of (year): Bronchitis: _________ Asthma: _____________
Emphysema: __________ Tuberculosis: ___________________
Recurrent pneumonia: _________________________________
Exposure to noxious fumes/allergens, infectious agents/diseases.
poisons/pesticides: __________________________________
Smoker: _________ Packs/day: __________ # of years:_______
Use of respiratory aids: _______ Oxygen: (type/frequency):____
Medications/herbals: ___________________________________
Safety
Subjective (Reports)
Allergies/sensitivity (medications, foods, environment, latex):
_______________________________________
Type of reaction: ___________________________________
Blood transfusion/number: _______ Date: ________________
Reaction (describe): ________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
_____________________________________________________
Exposure to pollution, toxins, poisons/pesticides, radiation:
______________________ (describe reaction):
_____________________________________________________
Geographic areas lived in:/visited: ________________________
Immunization history: Tetanus: ____ MMR: ____ Polio: ______
Influenza: ____ Pneumonia: ____ Hepatitis: ____ HPV: _____
Altered/suppressed immune system (list cause): ______________

History of sexually transmitted disease (data/type): ___________

Testing:__________________ __________________________
High risk behaviors: ____________________________________
Uses seat belt regularly: _________________________________
Other safety devices: __________________________________
Workplace safety/health issues (describe): ___________________
Currently working: ____________________________________
Rate working conditions (e.g. safety, noise, heating, water,
Ventilation): _________________________________________
History of accidental injuries: _____________________________
Fractures/dislocations: ___________________________________
Arthritis/unstable joints: ___________ Back problems: _________
Skin problems (e.g. rashes, lesions, moles, breast lumps,
enlarged nodes) describe: _______________________________
Delayed healing (describe): _______________________________
Cognitive limitations (e.g. disoriented, confusion): _____________
Sensory problems (e.g. impaired vision/hearing. Detecting
heat/cold, taste, smell, touch): ____________________________
Prostheses: __________ Ambulatory devices: _________________
Violence (episodes or tendencies): __________________________
Sexuality (Component of Social Interaction)
Subjective (Reports)
Sexually active: _____ Birth control method: _________________
Use of condoms: _______________________________________
Sexually concerns/difficulties (e.g. pain, relationship, role): ______
Recent change in frequency/interest: ________________________
Male: Subjective (Reports)
Circumcised: _______ Vasectomy(date): ___________________
Prostate disorder: ______________________________________
Practice self-exam: Breast: _________ Testicles: _____________
Last proctoscopic/prostrate exam: _____ Last PSA/date: _______
Medications/Herbals: ___________________________________

Objective (Exhibits)
Respirations (spontaneous/assisted): _________ Rate: ________________
Depth: ____________ Chest excursion (e.g. equal/unequal): __________
Use of accessory muscles: _____________________________________
Nasal flaring: ______________________ Fremitus: _________________
Breath sounds (presence/absence; crackle wheezes): __________________
Egophony: _________________________________________________
Skin/ mucous membrane color (e.g. pale, cyanotic) ___________________
Clubbing of fingers: ____________________________________________
Sputum charasteristics: __________________________________________
Mentation (e.g. calm, anxious, restlessness): _________________________
Pulse oximetry: _______________________________________________

Objective (Exhibits)
Body temperature/ method: (e.g. oral, rectal, tympanic): ______________
Skin integrity (mark location on diagram): Scars: ___________________
Bruises: ___________ Rashes: ___________ Abrasions: ____________
Lacerations: _________ Ulcerations: _________ Blisters: ___________
Drainage: ___________ Burns (degree%): _______________________

Musculoskeletal: General strength: ________ Muscle tone: ____________

Gait: _____________ ROM: _________ Paresthesia/paralysis: _________
Results of testing (e.g. cultures, immune function, TB, hepatitis):
___________________________________________________________

Objective (Exhibits)
Genitalia: Penis: Circumcised: __________ Warts/lesions: _____________
Bleeding/discharge: __________ Testicles 9e.g. lumps): _____________
Vasectomy: ________________________________________________
Breasts examination: __________________________________________
Test results: PSA: _____________ STD: __________________________

Sexuality (Component of Social Interaction) (continued)

Female: Subjective (Reports)
Menstruation: age at menarche: ______ Length of cycle: ____________
Duration: _______ Number of pads/tampon used/day: ____________
Last menstrual period: ______________________________________
Bleeding between periods: ___________________________________
Reproductive: Infertility concerns: _____________________________
Type of therapy: __________________________________________
Para: _________ Gravida: ___________ Due date: ______________
Menopause: ________ Last period: ____________________________
Hysterectomy (type/date): ___________________________________
Problem with: Hot flashes: ____________ Night sweats: __________
Vaginal lubrication: ____ Vaginal discharge: ___________________
Hormonal therapies: ________________________________________
Osteoporosis medication: __________________________________
Breasts: Practices breast self-exam: ____________________________
Last mammogram: ________________________________________
Last PAP smear: ___________________________________________
Social Interactions
Subjective (Reports)
Relationship status (check): Single: _________ Married: ___________
Living with partner: _______ Divorced: ________ Widowed: ______
Years in relationship: _____ Perception of relationship: ___________
Concerns/stresses: _________________________________________
Role within family structure: __________________________________
Number/age of children: ______________________________________
Perception of relationship with family members: ___________________
Extended family: ____________________________________________
Other support person (s): _____________________________________

Ethnic/cultural affiliations: _____________________________________

Strength of ethnic identity: ____________________________________
Lives in ethnic community: ____________________________________
Feelings of (describe): Mistrust: _______ Rejection: __________________
Unhappiness: _____________ Loneliness/isolation: _________________
Problems related to illness/condition: ______________________________
Problems with communication (e.g. speech, another language, brain injury):
_____________________________________________________________
Use of speech /communication aids (list): _________________________
Interpreter needed: _______ Primary language: ____________________
Teaching/Learning
Subjective (Reports)
Communication: Dominant language (specify): _______________________
Second language: _______ Literate (reading/writing): ________________
Education level: ______________________________________________
Learning disabilities (specify): ___________________________________
Cognitive limitations: __________________________________________
Culture/ethnicityL Where born: ____________________________________
If immigrant, how long in this country: ____________________________
Health and illness beliefs/practices/ customs: _________________________
Which family member makes healthcare decisions/is
Spokesperson for client: _________________________________________
Presence of advance directives: ______ Code status: ____________________
Durable Medical Power of Attorney: _______________________________
Designee: _____________________________________________________
Health goals: ___________________________________________________
Current health problem: ___________________________________________
Client understanding of problem: ___________________________________
Special healthcare concerns (e.g. impact of
religious/cultural practices): ________________________________________

Objective (Exhibits)
Breasts examination: _________________________________________
Genitalia: Warts/lesions: ______________________________________
Vaginal bleeding/discharge: _________________________________
Test results: PAP: ____________________________________________
Mammogram: ______________________________________________
STD: _____________________________________________________

Objective (Exhibits)
Communication/speech: Clear: _____________________________________
Slurred: ______________________________________________________
Unintelligible: _________________________________________________
Aphasic: _____________________________________________________
Unusual speech pattern/impairment: _______________________________
Laryngectomy present: __________________________________________
Verbal/nonverbal communication with family/SO(s): ___________________
Family interaction (behavioural) pattern)

Physical layout of home (specify): _________________________________

Prescribed medications: Drugs: ______________ Dose: _________________

Times (circle last dose): _______ Take regularly: ____________________
Purpose: ____________ Side effects/problems: _____________________
Nonprescription drugs/frequency: OTC drugs: ________________________
Vitamins: _______________ Herbals: _____________________________
Street drugs: _____________ Alcohol (amount/frequency) ______________
Tobacco: ________ Smokeless tobacco: ___________________________
Admitting diagnosis per provider: __________________________________
Reason for hospitalization/visit per client: ____________________________
History of current problem: _______________________________________
Expectations of this hospitalization/visit: ____________________________
Will admission cause any life changes (describe): _____________________
Previous illnesses and/or hospitalization/surgeries: ____________________
_____________________________________________________________
Evidence of failure toimprove: ____________________________________
Last complete physical exam: _____________________________________

Teaching/Learning (continued)
Subjective (Reports)
Familial risk factors (indicate relationship):
Diabetes: __________ Thyroid (specify) :_______________
Tuberculosis: ________ Heart disease: ______ Stroke: _____
Hypertension: _____ Epilepsy/Seizures: _________________
Kidney disease: __________ Cancer: ____________________
Mental illness/depression: ____________ Other:

Discharge Plan Considerations

Projected length of stay (days or hours): 4 days post op
Anticipated date of discharge: Feb 12, 2015
Date of information obtained: August 3, 2015
Resources available: persons: patients mother
Financial: Indigent
Community supports: Referred to Sta Cruz Health Center for nutritional and
Psychological management
Groups: none
Areas that may require alteration/assistance
Food preparation: _______ Shopping: ________ Transportation: _________
Ambulation: ________ Medication/IV therapy: _______________________
Treatments: ___________________ Wound care: ____________________
Supplies: ____________________ Self-care (specify): _________________
Homemaker/maintenance (specify): ________ Socialization: ____________

Anticipated changes in living situation after discharge: Depression

Living facility other than home (specify): __________________________
Referrals (date/source/services): Social Services: ______________________
Rehab services: _______ Dietary: ___________ Home care: ____________
Resp/O2: _________________ Equipment: __________________________
Supplies: _________________ Other: ______________________________