Assessment Tool Format

COLLEGE OF NURSING
Xavier University
Ateneo de Cagayan
LEVEL IV
NURSING HISTORY AND ASSESSMENT RECORD
I. PATIENT’S PROFILE
Name of patient: Diagnosis:
Age: Attending physician:
Religion:
Date and time of admission: Civil Status:

Language/dialect spoken:
Informant:
Temperature: Pulse: Respiration: BP:
O2 sat: Height: Weight:
Chief complaint/ reason for hospitalization:
History of present illness:
Family Medical History:

( ) Heart disease ( ) Lung disease ( ) Substance Abuse
( ) Hypertension(both parents and patient) ( ) Renal disease
( ) Stroke ( ) Cancer
( ) Others:
II. FUNCTIONAL PATTERN
A. NUTRITION/METABOLLIC PATTERN
Meal Pattern:
Appetite: ( ) Good ( ) Fair ( ) Poor
Changes in eating habit: ( ) Yes ( ) No
Appetite changes: ( ) Yes ( ) No
Weight loss/gain:
Special diet:
Comments/ Nursing problems identified:
BMI ( kg/m² )= (weight in pounds * 703) =

height in inches²
BMI score range:
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater
B. ELIMINATION PATTERN
Bladder : ( ) No difficulty ( ) Dysuria ( ) Oliguria
( ) Incontinence ( ) Nocturia ( ) Anuria
( ) UTI ( ) Stones ( )On catheter
Comments/Nursing problems identified:
Bowel: ( ) No difficulty ( ) Constipation ( )

COlostomy
( ) Incontinence ( ) Ileostomy
C. SLEEP/REST PATTERN
( ) No difficulty ( ) Yes (describe)
Use of sleeping aids: ( ) Yes ( ) No
D. ACTIVITY/ EXERCISE
Activities of Daily Living ( I= Independent; A=w/ Assistance; D=Dependent)
( ) Eating ( ) Bathing ( ) Dressing
( ) Grooming ( ) Toileting ( ) Ambulating
Activity Level: ( ) Active ( ) Sedentary

E. COGNITIVE PERCEPTION PATTERN

Glasses: ( ) Yes ( ) No Contact Lens: ( ) Yes
( ) No
Hearing Aids: ( ) Yes ( ) No [ ] right
[ ] right [ ] left
[ ] left Prosthesis: ( ) Yes ( )No
[ ] right [ ]left
F. BEHAVIOR PATTERN (COPING/ VALUES)

Behavior: ( ) Relaxed ( ) Mildly Anxious
( ) Moderately Anxious ( ) Very Anxious
Psychiatric History:"
SUBSTANCE ABUSE:
Tobacco ( ) Yes (X) No
Drugs ( ) Yes (X) No
Alcohol ( ) Yes (X) No
Cigarrete/Cigar/pipe ( ) Yes (X) No
G. PAIN
( ) None ( ) Present (describe)
Present pain management:
H. SEXUALITY/ REPRODUCTION HEALTH

Date of last Pap Smear:
Is Patient pregnant? ( ) No ( ) Unsure ( ) Yes, # of weeks
Breast (cyst/lump/discharge): ( ) No ( ) Yes
Testicular/prostate problem: ( ) No ( ) Yes
Birth Control: ( ) NA ( ) No ( ) Yes (describe)
I. ROLE RELATIONSHIP PATTERN

Occupation:
With whom does patient live:
Anticipating to return home: ( ) Yes ( ) No:
Persons available to assist at home:
III. PHYSICAL ASSESSMENT (Indicate subjective and objective cues for

abnormalities noted.)
A. NEUROLOGICAL ASSESSMENT
SUBJECTIVE OBJECTIVE
Alert and oriented to person, place and time
Pupils equally round & reactive to light
Paresthesia (weakness) or paralysis of extremities __________
No difficulty of speech and swallowing noted ________
B. RESPIRATORY ASSESSMENT
Resp. 12-22 cpm at rest
Respirations quiet and regular
Breath sounds in both lung fields clear
Nail beds and lips pink
C. CARDIOVASCULAR ASSESSMENT
Regular apical pulse; Heart rate 60-100 bpm.
No complaints of chest pain and edema
D. PERIPHERAL-VASCULAR ASSESSMENT
Extremities pink, warm & movable w/in
normal ROM Peripheral pulses palpable
No edema No complaints of numbness/
calf tenderness
E. GENITOURINARY ASSESSMENT
Voiding without discomfort or difficulty
Urine clear, frequency w/in own pattern
No unusual vaginal or penile
discharges/ irritation noted
F. MUSCULOSKELETAL ASSESSMENT
Absence of joint swelling & tendernesss,
no evidence of inflammation.
Normal ROM of all joints. No muscle
Weakness. No complaints of back pain

G.INTEGUMENTARY ASSESSMENT
Skin color w/in patient’s norm
Skin warm, dry, intact
Decubitus/ buirns present? ( ) yes ( ) no
Skin/Burns
CURRENT MEDICATIONS :
Does the client have correct knowledge of the medications taken? If no, provide
comments.
1. ( ) Yes ( )
No___________________
2. ( ) Yes ( )
No___________________
3. ( ) Yes ( )
No___________________
4. ( ) Yes ( )
No___________________
5. ( ) Yes ( )
No___________________
6. ( ) Yes ( )
No___________________
7. ( ) Yes ( )
No___________________
8. ( ) Yes ( )
No___________________
9. ( ) Yes ( )
No___________________
10. ( ) Yes ( )
No___________________
PRIORITY NURSING DIAGNOSIS IDENTIFIED:

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COLLEGE OF NURSING

Age: Attending physician:

Date and time of admission: Civil Status:

Temperature: Pulse: Respiration: BP:

O2 sat: Height: Weight:

Chief complaint/ reason for hospitalization:

History of present illness:

Family Medical History:

Comments/ Nursing problems identified:

BMI ( kg/m² )= (weight in pounds * 703) =

Comments/ Nursing problems identified:

Bowel: ( ) No difficulty ( ) Constipation ( )

Activity Level: ( ) Active ( ) Sedentary

E. COGNITIVE PERCEPTION PATTERN

F. BEHAVIOR PATTERN (COPING/ VALUES)

Comments/Nursing problems identified:

H. SEXUALITY/ REPRODUCTION HEALTH

I. ROLE RELATIONSHIP PATTERN

With whom does patient live:

Anticipating to return home: ( ) Yes ( ) No:

Persons available to assist at home:

Comments/Nursing problems identified:

III. PHYSICAL ASSESSMENT (Indicate subjective and objective cues for

Pupils equally round & reactive to light

Paresthesia (weakness) or paralysis of extremities __________

No difficulty of speech and swallowing noted ________

Respirations quiet and regular

Breath sounds in both lung fields clear

Nail beds and lips pink

No complaints of chest pain and edema

normal ROM Peripheral pulses palpable

No edema No complaints of numbness/

Urine clear, frequency w/in own pattern

No unusual vaginal or penile

discharges/ irritation noted

Normal ROM of all joints. No muscle

Weakness. No complaints of back pain

Skin warm, dry, intact

Decubitus/ buirns present? ( ) yes ( ) no

Comments/Nursing problems identified:

PRIORITY NURSING DIAGNOSIS IDENTIFIED:

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