New Adult Ms Tool-with Data
Content
ADULT ASSESSMENT TOOL
Objective (Exhibits)
Observed response to activity: Unable to tolerate ambulation; radial
pulse increase by 10-15 bpm from basal pulse
Specific activity: Walk (Assuming you let pt walked-IF NOT CONTRA)
GENERAL INFORMATION
Name: Last Name / First Name / Middle Initial
______
Age: _______
Birthdate: MM/DD/YY____________
Address: ______________________________________________
Admission: Date:_____ Time: _________
From: Home: _________________________________________
Hospital: ________________________________________
Others: Ambulance – Paramedics pick-up from home
HEALTH HISTORY
Reason for this visit (chief complaint): “Masaki tang dibdib ko” or
Just plain chest pain, SOB, dizziness, etc.
History of Present Illness: Condition started 2 weeks PTA as
increasing body weakness, limiting performance of household chores,
swelling of ankles & feet late PM, & nocturnal dieresis 60cc X4. 5 days
PTA, felt on and off chest heaviness aggravated by activity, radiating
to left arm, relieved by rest & unrecalled medications. Consulted
family physician who referred her to this institution.
History of Past Surgeries/ Hospitalizations: No previous hospitalization
and surgery of Unremarkable medical/surgical history
Diagnoses/ Impressions: CAD, CKD, DM Type 2
Source of Information: Patient and daughter
Date: 03/30/11
ACTIVITY/ REST
Subjective (Reports)
Occupation: Government employee
Able to participate in usual activities/ hobbies: Yes – but with support
or assistance
Leisure time/ diversional activities: Reading pocket books, watching
Mara Clara
Ambulatory: Yes with assistance or support (Y/N-describe)
Gait (describe): Normal / limp/ unsteady/ loss of balance/fear of falling
(Others: spastic, scissors, steppage, ataxic, parkinsonian)
Activity level (sedentary to very active): sedentary/moderately
active/vigorously active/extremely active
Daily exercise (type): brisk walking
Muscle mass/ tone/ strength (e.g normal, increased, decreased):
_______________________________________________________
_______________________________________________________
History of problems/ limitations imposed by condition (e.g. immobility,
can’t transfer, weakness, breathlessness):
________________________________________________________
________________________________________________________
________________________________________________________
Feelings (e.g. exhaustion, restlessness, can’t concentrate
dissatisfaction): ___________________________________________
________________________________________________________
Sleep: Hours 6 hours
Naps: 20 mins X2/day (10AM/3PM)
Insomnia:Y/N
Type: Initial / terminal / Intermittent
Rested on awakening: Y/N
Excessive grogginess: Y/N
Bedtime rituals: Glass of milk, scented candle bath
Relaxation techniques: yoga, spa, bubble bath
Sleeps on more than one pillow: Y/N # of pillows (due to DOB?)
Oxygen use (type): 4LPM/NC
When used: Continuous
Objective data
Medications/ herbals for/affecting sleep: Y/N- list the medications
________________________________________________________
______________________________________________________
Before Activity
HR – 90
RR – 20
BP – 140/90
Immediately after
100
25
150/100
After 5 minutes
90
20
140/90
Pulse oximetry: 94% at 4LMP/NC (90% Room Air)
Mental status (e.g. cognitive impairment/ withdrawn/ lethargic): LOC’sconscious, lethargic, coherent
Muscle mass/ tone (e.g. normal, flaccid, hypertonic, hypotonic,
spastic, rigid) : Generally firm
Posture (e.g. normal, stooped, curved spine): erect, slumped, tripod
position
Tremors: Y/N Location: describe location of tremores
ROM: Describe: Full ROM in all
extremitites / encircle the joint in the
illustration with problem
_______________________________
_______________________________
_______________________________
Strength: 4/5 in all extremities
Uses Mobility Aid/s: Y/N
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
CIRCULATION
Subjective (Reports)
History of/ Treatment for (date):
High blood pressure: Yes/No ONLY
Head injury: __________________________________________
Stroke: ______________________________________________
Hemoptysis: __________________________________________
Heart Problem/surgery: _________________________________
Syncope: _____________________________________________
Spinal cord injury/ dysreflexia: ____________________________
Palpitations:___________________________________________
Bleeding tendencies’ episodes: ___________________________
Specify: ____________________________________________
Varicosities: __________________________________________
Heart problems/ Surgery: ________________________________
Thrombophlebitis: ______________________________________
Pain in legs with activity: _________________________________
Extremities: Numbness: Y/N Location: Describe location
Tingling: Y/N Location: Describe location
Slow healing wound:
Stages: _______
Site (describe): ______________________________
Medication/herbals: Unrecalled
Objective (Exhibits)
Color:Skin: Sallow Mucous membrane: Pinkish/Brown spots
Lips:Red
Sclera: Dirty
Conjunctiva: Pale
Nailbeds: Thick, whitish
Skin moisture (e.g. dry, diaphoretic): Diaphoretic
Blood pressure: lying:
R: _______ L ___________
Standing:
R: _______ L ___________
Pulse pressure: 140/90
Auscultatory gap: Present after 70 diastolic
Page 1
Pulses: Carotid: 70
Describe: 4+
Temporal:__________
Describe:____________________________________________
Brachial: __________
Describe: ___________________________________________
Radial: ____________
Describe:____________________________________________
Ulnar: _____________
Describe: _____________________________________
Dorsalis pedis: ___________
If dorsalis pedis absent or abnormal,
post tibial_______________________________________
If post-tibial pulse absent or abnormal,
popliteal: ______________________________________
If popliteal pulse absent or abnormal,
femoral: ______________________________________
Cardiac (palpation): thrill Y/N
heaves: Y/N
Heart sounds (auscultation):
Rate:96
Rhythm: Irregular Quality: +2
Friction rub: Y/N
Murmur (describe location/ sounds): Y/N
Vascular bruit (location): Y/N
Jugular vein distention: Yes
Breath sounds: location: Rales, bibasal (Crackles, wheezes, rhonchi)
Description: Coarse / fine
Extremities:
temperature: warm/cold color: pale capillary refill: 1-2 secs
Homan’s sign: Y/N
varicosities (location): Y/N
Nail abnormalities: :Leukonychia, splinter hemorrhage, clubbing
edema(location/ severity +1 to +4): +3, lower extremities, bilateral
Distribution/ quality of hair: Equal (velus & terminal hairs)
Skin lesions: type:Macule, papule, vesicle, bullae, keloid, scar
location: describe the location + size
color: Reddish, necrotic, purplish
Nursing Diagnosis:
________________________________________________________
________________________________________________________
_____________________________________________________
EGO INTEGRITY
Subjective (Reports)
Marital status: Singe, married, separated, widow, complicated?
Expression of concerns (e.g. financial, lifestyle or role changes):
“Walang mag-aalaga sa mga anak ko” / None as of the moment
Stress factors: Workload, supervisor, noise
Usual ways of handling stress: watching TV, spa, yoga
Ways of expressing feelings:
Anger: Break glass, shout at co-workers, be quiet
Anxiety: nail-biting
Fear: go to church, magtago sa ilalim ng bed
Grief: cry, pray
Others (hopelessness, helplessness, powerlessness): pray
Cultural factors/ ethnic ties: Canao
Ethnic group: Kankanaey
Religious affiliation: Roman Catholic
Active/ Practicing: Y/N
Practices (prayer/meditation, etc.): Novena, rosary
Religious/ Spiritual concerns: Anti-RH bill, no to abortion
Desires clergy visit: Y/N
Expression of sense of connectedness/ harmony with self and
others: Prayer meetings, social gatherings, bingo social
Medications/ Herbals: List of medications affecting ego-integrity
Objective (Exhibits)
Emotional status (check those that apply):
Calm: ______ Anxious:_________ Angry: _______________
Withdrawn: __________ Fearful: ______Irritable: __________
Restive: ________ Euphoric: ___________
Observed body language (e.g. pacing, fidgeting): nail-biting, arms
crossed over chest, looks at window and time
Observed physiological response (e.g. pallor, flushing): pallor, sallow
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
ELIMINATION
Subjective (Reports)
Usual bowel elimination pattern: Once a day, before taking bath
Character of stool: Formed Color of stool: Clay
Date of last BM and character of stool: (describe): 03/29/11 – formed
in consistency, yellowish in color, approximately 50cc, malodorous
History of bleeding (describe): Y/N..2 years ago, during defecation,
fresh blood approx 20 cc 3X 2 days – no interventions done
Hemorrhoids/ Fistula: Y/N
Acute: <3 days
Constipation: acute: Y/N chronic: Y/N
Chronic: >3 days
Diarrhea: acute: Y/N chronic: Y/N
Bowel incontinence: Y/N
Laxative: Y/N how often: ________________________
Enema/ suppository: Y/N how often: ______________
Usual voiding pattern and character of urine: once every 4 hours,
approx 100 cc per void, nocturnal dieresis 4X
Difficulty voiding: Y/N
Urgency: Y/N
Bladder spasm: Y/N
Frequency: Once every 4 hours/ 4X
Retention: Y/N
Burning: Y/N
Urinary incontinence (type/ time of day when it usually occurs):
_______________________________________________________
_______________________________________________________
History of kidney/ bladder disease: CKD
Diuretic use: Y/N (Specify drug)
Meds/Herbal: List medications related to elimination taken by patient
Objective (Exhibits)
Abdomen (palpation): Soft/ firm: Soft, smooth, non-tender
Tenderness/pain (quadrant/ location): Pain at RLQ
Distention: Y/N
Palpable mass/ location: Y/N
size/ girth: 35 inches at largest diameter
Abdomen (auscultation):
bowel sounds (location/ type):
Normoactive at regular intervals (15 per quadrant)
Costovertebral Angle tenderness: Y/N
Bladder palpable: Y/N
Hemorrhoids/ fistulas: Y/N
Presence/ use of cathether or continence devices:
Y/N Describe: IFC/Diapers
Ostomy devices (describe appliance and location)
Ileostomy appliance at RLQ
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
FOOD/ FLUID
Subjective (Reports)
Usual food intake:
3 # of meals daily: 2 snacks
(# and time consumed) 10AM/3PM
Dietary pattern/ content:
B: fried rice, eggs, coffee, dried fish
L: rice, nilagang beef/ sinigang pork, pakbet
D: rice, chopsuey, fried fish
Snacks: soda, banana que, chicken sandwich
Last meal consumed/ content: If no food taken X 24 hrs
Food preferences: rice, vegs, pork, beef, chicken
Food allergies/ intolerances: crustaceans (shrimp, lobster, crabs)
Page 2
Cultural or religious food preparation/ concerns/ prohibitions: dinuguan
Usual appetite: consumes 70-80% of food served
or plate wastes
Change in appetite: consumes 40% of food served
Usual weight: 75-80 kg
Unexpected/ undesired weight loss/ gain: 2 kg gained
Nausea/ vomiting: Y/N
Related to: identify precipitating factor
Heartburn: Y/N
Indigestion: Y/N
related to: identify precipitating factor
relieved by: eating , vomiting, medications
Chewing or swallowing problems:
Gag/ swallow reflex present: Y/N
Facial injury/ surgery: Y/N
Stroke/ other neurological deficit: Y/N (Paralysis, impairment of
speech, tremors, dystonia, loss of balance, etc
Diabetes: Y/N- type 1 or type 2
Controlled with diet/pills/insulin: OHA, insulins (identify brand used)
Vitamin/ food supplements: _______________________________
Medication/ herbals: _____________________________________
Objective (Exhibits)
Current weight: in kg or in lbs Height: feet or cm
Body built: endomorph, mesomorph, ectomorph
BMI: underweight, overweight obese
Skin turgor: good or poor
Mucous membranes (moist/ dry): moist or dry, plus color
Edema: generalized: Y/N dependent: Y/N
feet/ ankles: Y/N (grade-1+, 2+, 3+, 4+)
Periorbital: Y/N abdominal/ascites: Y/N + measurement
Breath sounds (location/ adventitious sounds): (data can be written at
respiratory portion page 4)
Condition of teeth/ gums: complete set of teeth, healthy pinkish gums
Dentures (full/partial): Y/N, if yes-complete or partial (# of teeth)
Loose/ absent teeth/ poor dental care: Y/N(identify absent/loose tooth)
sore mouth/ gums: Y/N – identify specific areas
Appearance of tongue: pinkish, symmetrical, no tongue deviation
mucous membranes: moist, pinkish
Abdomen: bowel sounds (quadrant/ location): 20-15 per quadrant
hernia/ masses: Y/N (identify area/location)
Urine S/A or chemstix: Sugar/ Albumin +2
Serum glucose (glucometer): 190 mg/dl
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
HYGIENE
Subjective (Reports)
Ability to carry out activities of daily living: independent/ dependent
(level 1= no assistance needed to 4= completely dependent): 2
Mobility: Assistance needed (describe): Y/N
Assistance provided by: daughter, husband (identify SO)
Equipment/ prosthetic devices required: Y/N, cane, walker, etc.
1-no assistance
Feeding: Oral, NGT, PEG Tube
2-remind pt to do it independently
Help with food preparation: Y/N
3-substantial assistance
Help with eating utensils: Y/N
4-completely dependent
Hygiene:
Get supplies: Y/N
Wash body or body parts: Y/N
Can regulate bath water temperature: Y/N22c
Get in and out alone: Y/N
Preferred time of personal care/ bath: 10AM
Dressing: Y/N
Can select clothing and dress self: Y/N
Needs assistance with (describe): daughter / SO
Toileting:
Can get to toilet or commode alone: Y/N
Needs assistance with (describe): Daughter / SO
Objective (Exhibits)
General appearance: Manner of dressing: clean, appropriate to age
and climate, fit to body
Grooming/ Personal habits: appears clean & groomed appropriate for
age and ethnic group
Bath: Y/N
Shampoo Y/N Perineal Care Y/N
Oral Care Y/N`
Condition of hair/ scalp: dry, scaly, brittle hair, healthy hair & scalp
Body odor: Y/N
Use of deodorant: Y/N
Presence of vermin (lice, scabies): Y/N
Nursing Diagnosis: ________________________________________
NEUROSENSORY
Subjective (Reports)
History of brain injury, trauma, stroke (residual effects): Y/N-when?
What interventions was done
Fainting spells/ dizziness: Y/N
Headaches (location/type/frequency): Y/N…temporal, tension,
migraine, once a week after reading
Tingling/ numbness/ weakness (location): Y/N at lower extremities
Seizures: Y/N
History or new onset seizures
Type: grand mal, tonic, clonic, atonic Frequency: Once a year
Aura: Y/N
Postictal state: Y/N , altered state of consciousness
How controlled: medications –identify
Vision:
Loss or changes in vision: Y/N
Date of last exam: March 2000
Glaucoma: Y/N Cataract: Y/N
Eye Surgery (type/ date): LASIK Surgery 2002
Hearing loss: Y/N Sudden or gradual: gradual
Date of last exam: _____________________________________
Sense of smell (changes): Y/N…Anosmia
Sense of taste (changes): Y/N
Epistaxis: Y/N
Other: _______________________________
Objective (Exhibits)
Mental status (note duration of change): Put a check mark
Oriented/ disoriented: √
Person: √
Place: √
Time: √
Situation: or events √
Check all that apply:
Alert: _______ Drowsy: ________ Lethargic: ______________
Stuporous: ______ Comatose: ____Cooperative: _____________
Combative: ___________ Agitated/ restless: _____________
Follows commands: ____________
Delusions (describe): grandeur, jealousy, guilt, persecutory
Hallucinations (describe): visual, auditory, auditory
Affect (describe): flat, blunted
Speech: aphasic, slurred, spontaneous, appropriate use of words
Memory
Recent: able to recall… Remote: able to recall…
Glasgow Coma Scale: 15/15 or (E4, M6, V-Intubated)
Test
Score
EYE OPENING RESPONSE
SCORE
Spontaneously
4
To speech
3
To pain
2
None
1
MOTOR RESPONSE
Obeys
Localizes
Withdraws
Abnormal flexion
Abnormal extension
None
VERBAL RESPONSE
Oriented
Confused
Inappropriate words
Incomprehensible
None
TOTAL SCORE
6
5
4
3
2
1
5
4
3
2
1
15
Page 3
Cranial Nerves Assessment (describe result)
CN 1 : ________________________________________________
CN 2: ________________________________________________
CN 3:_________________________________________________
CN 4: ________________________________________________
CN 5: ________________________________________________
CN 6: ________________________________________________
CN 7: ________________________________________________
CN 8: ________________________________________________
CN 9: ________________________________________________
CN 10: _______________________________________________
CN 11: _______________________________________________
CN 12: _______________________________________________
Wears glasses Y/N Contacts: Y/N
Hearing aids: Y/N
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
PAIN/ DISCOMFORT
Subjective (Reports)
Location: chest
Quality: Heavy
Intensity ( 1,2,3,4,5,6,7,8,9,10 ) 6/10
Mini Mental Status Examination
Folstein Mini Mental Status Examination
Task
Instructions
Date
"Tell me the date?" Ask for
Orientation omitted items
One point each for
year, season, date,
day of week, and
month
Place
"Where are you?" Ask for
Orientation omitted items.
One point each for
state, county, town,
5
building, and floor or
room
5
Register 3
Objects
Name three objects slowly
and clearly. Ask the patient
to repeat them.
One point for each
item correctly
repeated
3
Serial
Sevens
Ask the patient to count
backwards from 100 by 7.
Stop after five answers. (Or
ask them to spell "world"
backwards.)
One point for each
correct answer (or
letter)
5
Recall 3
Objects
Ask the patient to recall the
objects mentioned above.
One point for each
item correctly
remembered
3
Naming
Point to your watch and ask
the patient "what is this?"
Repeat with a pencil.
One point for each
correct answer
2
Repeating
a Phrase
Ask the patient to say "no ifs, One point if
1
ands, or buts."
successful on first try
Give the patient a plain piece
of paper and say "Take this
Verbal
One point for each
paper in your right hand, fold
Commands
correct action
it in half, and put it on the
floor."
3
Show the patient a piece of
Written
paper with "CLOSE YOUR
Commands
EYES" printed on it.
1
Writing
Drawing
Scoring
Ask the patient to write a
sentence.
Radiation: left arm
Frequency: on & off
Precipitating factors: activity
Relieving factors : Pharmacologic: Unrecalled
Non-pharmacologic (e.g rubbing, rest, herbal): rest
Associated symptoms: swelling of lower extremities, sweating
Effect on: Daily activities: unable to do ADL’s
Relationships: No sexual activity, always fighting
Job: absenteeism
Enjoyment of life: limited to watching TV
Objective (Exhibits)
Grimacing: Y/N
Guarding affected area: Y/N
Narrowed focus: Y/N
Emotional response (e.g crying, withdrawn, anger): Sad
Vital sign changes (acute pain): BP: ________ PR: ________
RR: _________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
Scoring
One point if the
patient's eyes close
One point if sentence
has a subject, a verb, 1
and makes sense
One point if the
figure has ten
corners and two
Ask the patient to copy a pair intersecting lines
of intersecting pentagons
onto a piece of paper.
A score of 24 or above is considered normal.
1
30
Deep tendon reflexes (present/ absent): ________
(encircle joint with abonormal reflex, then rate)
Tremors: ________ Paralysis (R/L): _________
Posturing: _____________________________________________
RESPIRATION
Subjective (Reports)
Dyspnea related to: Orthopnea, exertion
Precipitating factors: Activity Relieving factors: Rest
Cough (describe): productive, non-pro, able or unable to expectorate
sputum (describe character): rusty, approx 10cc per expectoration
Requires suctioning Y/N
History of (year): bronchitis: √
asthma: √
emphysema: ____tuberculosis: __recurrent pneumonia: ______
exposure to noxious fumes/ allergens: ___
Infectious agents/ diseases/ poisons/ pesticides:
_______________________________________________________
Smoker: Yes: ___ No: ___
Type (e.g. menthol) ________ sticks/packs per day: ________
No. of Yrs: ____________
Use of respiratory aids: oxygen, nebulizers, ventilators, etc
Oxygen (type/ frequency): 4LPM / NC, FM, Non-rebreather, ect
Medications/ herbals: ______________________________________
_______________________________________________________
_______________________________________________________
Objective (Exhibits)
Respirations
Spontaneous: Rate: 96
Depth: deep
Assisted: Y/N Parameters: _______________________________
_____________________________________________________
O2 inhalation: Y/N Type: NC, FN, Non-rebreather
Flow Rate: ____________________________________________
Chest excursion (equal/ unequal): symmterical
Fremitus: buzzing at ulnar aspect of hand, more pronounced at..
Use of accessory muscles: Y/N…SCM, Scalene, trapezius
Nasal flaring: Y/N
Breath sounds: wheezes, rales, crackes, stridor
Egophony:muffled: Y/N
clear: Y/N
Skin/ mucous membrane color: Pinkish
clubbing of fingers: Y/N
Sputum characteristics: Yellowish-copious
Pulse oximetry: 94% at 4LPM/NC
Page 4
Mentation (e.g. calm, anxious, restless): calm, oriented to time, place,
person
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
SAFETY
Subjective (Reports)
Allergies/ sensitivity (medications, foods, environment, latex):
crustaceans, penicillin, laundry powder
Type of reaction: generalized rashes
_______________________________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
chicken pox, measles, mumps
Exposure to pollution, toxins, poisons/ pesticides, radiation
(describe reactions): Y/N – pesticides used by a farmer father
Living conditions (with whom/ location of residence): living with
daughter at a subdivision but near garbage pumping site
Travelled Places: Palawan, India
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
Put a check
mark/doses
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify): ______________________________________
Altered/ suppressed immune system (list cause): taking
corticosteroids, or anti-rejection drugs, anti-cancer drugs, etc
History of STD (date/ type): gonorrhoea 1998
test: VDRL test 1998
High risk behaviours: sexually active during prime of her life
Blood transfusion/ number: ___________ Type: _____________
Date: ______________________________
Reaction (describe): ___________________________________
_____________________________________________________
Use seat belt regularly: ____Bike helmets: ______
Other safety devices: ____________________________________
Work place safety/ health issues (describe): prolonged sitting, office at
3rdfloor, rest room at ground floor
Currently working: Y/N
Rate working conditions (e.g. safety, noise, heating, water,
ventilation): scale of 1-10, 5 in terms of above mentioned factors
History of accidental injuries: fall, 2005 due to wet floor
Skin problems (e.g. rashes, lesions, moles, breast lumps, enlarged
nodes) describe: petechiae at forearms and legs
Delayed healing (describe): Y/N … a lesion at right big toe due to
pedicure 2009, 6 months healing process
Cognitive limitations (e.g. disorientation, confusion): Y/N, describe
(Front)
(Back)
Results of testing (e.g. cultures, immune function, TB, hepatitis):
Laboratory results here…
Nursing Diagnosis: _____________________________________
_______________________________________________________
SEXUALITY (Component of Social Interaction)
Subjective (Reports)
Sexually active: Y/N
STI/ Birth control method: Y/N (describe)
Sexual concerns/ difficulties (e.g. pain, relationship, role): Y/N
describe
Recent change in frequency/ interest: loss of libido
FEMALE: Subjective (Reports)
Menstruation
Age at menarche: 9 years old__________________
Length of cycle: 28 days regular____________________
Duration: 4 days __________________________
Number of pads/ tampons used/ day: 3 pads/ moderately
soaked/day_________________________________
Last menstrual period: April 11, 2011_______________
Bleeding between periods: Y/N ____________
Reproductive Infertility concerns: None______________________
Type of therapy (hormones): None___________________________
Pregnant now: Y/N________ G: 3___ P: 2___ (TPAL): 2-0-0-2____
EDD: January 18 2012__________________________________
History of Present Condition: (Start, list and describe symptoms
chronologically from time/day of onset onwards)
Initial: Wt: 75 kg________
Vital signs: BP=120/80 mmHg HR= 80 beats/mn RR= 12 cycles/min
Temp. 37.5 C_______
Age of Gestation:20 weeks _______________
Labor
1.Abdominal Status: FU:20 cm ___ EFW: 50 grams________
AOG: 22 weeks ___
a) Presence of uterine contraction:
frequency
duration
interval
intensity
None as of
None as of
None as of
None as of
moment
moment
moment
moment
Every ___
60-90 seconds 1 minute
Mildminutes
moderatesevere
b) IE Result:
Sensory limitations (e.g. impaired vision/ hearing, detecting hot/cold,
taste. Smell, touch):_______________________________________
_______________________________________________________
Prostheses: Y/N Ambulatory devices: crutches, cane
Violence (episodes/ tendencies): Y/N
Objective (Exhibits)
Body temperature:37 °C
Skin integrity (e.g. scars, rashes, ulcerations, ulcerations, bruises,
blisters, burns – degree/ %, drainage) / mark location on diagram:
_______________________________________________________
time
Dilat’n
Efface’t
BOW
Cond.
station
discharges
Done By
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Past Medical History
a.) Includes childhood illnesses (mumps, measles, german
measles, poliomyelitis, etc)german measles, varicella
______________________________________________
______________________________________________
Page 5
b) Any previous health care contacts- Include diagnostic test
results and date : u/a, cbc, bld. Typing, glucose screening
test, utz result: laboratory results here…
c) Allergy- include food and drug hypersensitivity: Y/N describe
d) Use of OTC/prescribed drugs: Paracetamol, Decolgen, etc
e) Past pregnancies:
No. Of
Preg.
Yr
Method
of Del.
Place of
del./attended
by
Birth
wt
Cond’n
Condn of
baby
1
1986
NSVD
Home/
midwife
2.6
kg
Hospital/
physician
1.8
kg
Tolera
ted
labor
and
deliver
y
Arrest
in
labor
thus
CS
Adapte
d to
extraute
rine
environ
ment
Adapte
d to
extraute
rine
environ
ment
1
1990
LSCS
Prenatal History
d1) General physical and emotional state of the mother during
pregnancy: observed expected physiologic changes of
pregnancy , planned and accepted pregnancy, ______
__________________________________________________
d2) Prenatal check up/consultations:
1st trimester (frequency): once_________________________
Diagnostic & result: VDRL –negative resul, CBC- Hgb =8
g/dL, Blood type= B(+) Rh (-)_____________
2nd trimester:once _________________________________
Diagnostic & result: ultrasonography=singleton, male,..____
3rd trimester: no prenatal_____________________________
Diagnostic & result: none__________________________
d3) Pregnancy complications & discomforts during present
pregnancy(if any)- nausea and vomiting: Y/N_______________
loss of appetite: Y/N ____ edema: Y/N _____ UTI : Y/N _____
co morbid illness: hypertension,...______ Vag’l bleeding: Y/N
abnormal weight change: Y/N ______ HPN: Y/N _______
d4) Was pregnancy planned: Yes: ______ No: ______
when was quickening felt: 5 months gestation_____________
attitude of father: accepted pregnancy, supportive___________
place where mother plans to give birth: birthing facility/home
_________________________________________________
Gynecologic History (Date):
a.) Surgery affecting the: breast: Y/N _____ Mastectomy: Y/N ____
hysterectomy: Y/N ___ Hysterectomy: Y/N ___ TAHBSO : Y/N
b.) Ectopic pregnancy: Y/N _______
c.) Reproductive tract diseases: PID: Y/N ______
Polycystic ovarian disease: Y/N ______ H-mole : Y/N _____
Others: specify: STI__________________________________
d.)Breast:(symmetrical):symmetrical/assymetrical ______
size and shape ______ retractions/ dimpling: Y/N ______
nipple discharge: Y/N _______ redness of the skin: Y/N
_____ visible superficial veins: Y/N _____ lumps or masses
on both breasts: Y/N _______ axillary lymph node mass:
Y/N _____ tenderness: Y/N __________
d.) Abdomen: (minimal) gravidarum striae: Y/N _______
(protruded) umbilicus Y/N ______ fundic height 20 cm :
__________ tenderness: Y/N _______ (occasional/mild)
uterine contractions: (frequency /intensity/interval/duration)
________ fetal movement 10-12 ./ hour______________
bowel sounds:
no. per minute
25
*Leopold’s Maneuver:findings: describe:
LM I: round firm parts ______________________________
_______________________________________________
_______________________________________________
LM II: left: smooth flat, right: nodular prominences,
longitudinal lie, FHT site at LUQ______________________
_______________________________________________
LM III: irregular , soft parts__________________________
_______________________________________________
_______________________________________________
LM IV: engaged/ ballotable,/ completely flexed, partially
flexed, extended, military attitude _________________________
_______________________________________________
_______________________________________________
e.) Genitourinary tract:
(Darkly pigmented) inguinal region: Y/N _________________
vaginal secretions (watery or bloody): Y/N _______________
presence of haemorrhoids: Y/N ______________________
f.) Extremities: symmetrical length: Y/N _____________________
size upper and lower extremities: ___________________
edema: Y/N _ varicosity: Y/N __ limitation of ROM Y/N ____
swelling of joints: Y/N ______ peripheral pulses: _______
tenderness: Y/N ______ claudication: Y/N ___________
g.) Integumentary: gravidarum striae-: Y/N ____________________
specify location: abdomen______ lesions: ____ rashes: ___
hematoma/petechiae: Y/N _____ chloasma: Y/N _______
Post Partum
h.) Abdominal status:
location and size of the uterus: 1 cm below umbilicus,_______
condition of the uterus: soft boggy_______________________
i.)GUT status: presence of vaginal discharge: Y/N _________
amount: 4 fully soaked pads in 2 hours___ color: bright red___
condition of the perineum ( particularly if episiotomy is done):
eryhtematous, ecchymosed, approximately 5 cm on the RML
area ______________________________________________
functioning of the bladder (time and amount of first urine, time
of first BM postpartum) urine 250 mL 2 hours after delivery,
bowel movement after 8 hours of delivery _______________
_________________________________________________
j.) Emotional/ Psychological Status
postpartum blues: Y/N ________ depression: Y/N __________
heightened emotional reactions/labile moods: Y/N _________
_________________________________________________
Menopause: Y/N _____ onset: 55____________
Hysterectomy/ Oophorectomy: Y/N _________________________
Problem with: Vaginal lubrication: Y/N _____ hot flushes: Y/N _____
Vaginal discharge: Y/N ______ others: ____________________
Hormonal therapies: Y/N ________________________________
Osteoporosis medications: Y/N ____________________________
Practices BSE: Y/N ____ Last mammogram: date _______________
Last Pap smear: date_________ Results: ______________________
Objective (Exhibits)
Genitalia (warts/ lesions): none_______
STI test results: _________________________________________
vaginal bleeding/ discharge: ________
Management: Meds: prescribed:___________________________
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
MALE: Subjective (Reports)
Circumcised: Y/N
Practices self examination: Breast: Y/N
testicles: Y/N
Prostate disorder: Y/N
last prostocopic/ prostate exam: January 2008
last PSA date: Y/N (Prostate specific antigen test)
Medications/ herbals: ____________________________________
Objective (Exhibits)
Genitalia: Penis (circumcised): Y/N warts/ lesions: Y/N
bleeding/ discharge: Y/N Testicles (e.g. lumps): Y/N
Breast examination: Y/N
STI test results: __________________________________________
_______________________________________________________
Nursing Diagnosis: _______________________________________
_______________________________________________________
_______________________________________________________
Page 6
SOCIAL INTERACTIONS
Put a check mark
Subjective (Reports)
Relationship status:
Single: _____ Married: _______
Separated/ Annulled/ Divorced: ________ Widowed: ______
Living with (Specify): ____________________________________
Yrs of Relationship:__________
Perception of relationship: happy living alone
Concerns/ stresses: no one to talk to when sad
Role within family structure: breadwinner
Number/ Age of children: __________________
Perception of relationship with family members: happy being the lone
provider to the needs of children
Extended family: Y/N
other support persons: __________________________________
Ethnic/ Cultural affiliations: _______________________________
Strength of ethnic identity: _______________________________
Feelings of (describe):
Mistrust: Y/N
Rejection: Y/N
Unhappiness: Y/N, sometimes, seldom, rare
Loneliness/ Isolation: Y/N
Problems related to illness/ condition: Unable to work
Problems with communication (e.g. speech, another language, brain
injury): ______________________________________________
Use of speech/ communication (list)_______________________
____________________________________________________
Is interpreter needed:Yes ______ No ______
Primary language: _________________________
Objective (Exhibits)
Communication/ speech: Clear: ______ Slurred: _______
Unintelligible: _____ Aphasic: ______
Put a check mark
Unusual speech pattern/ impairment: _____
Laryngectomy present: _____
Family interaction (behavioural pattern): open communication to
children, free to express their emotions
Nursing Diagnosis: _____________________________________
________________________________________________________
______________________________________________________
TEACHING/ LEARNING
Subjective (Reports)
Communication Dominant Language (specify):
_______________________________________________________
Second language: _______________________________________
Literate (reading/ writing): ______________
Educational level: _____________________________________
Learning disabilities (specify): ___________________________
Cognitive limitations: ____________________________________
Ethnic Affiliation: __________________________
Health and illness beliefs/practices/ customs: _______________
_______________________________________________________
Which family member makes healthcare decisions/ is spokesperson
for client: _________________________________
Presence of Advanced directives: _______ Code status: _______
Durable medical power of attorney: ___________
Designee: ____________________________________________
Health goals: ___________________________________________
Current health problem: client understanding of problem:
________________________________________________________
______________________________________________________
Special health concerns (e.g. impact of religious/ cultural practices):
_____________________________________________
_______________________________________________________
Familial risk factors (indicate relationship):
Diabetes: _____________ Thyroid (specify): ____________
Tuberculosis: ____________ Heart disease: __________
Stroke: __________________ Hypertension: ____________
Cancer: ________________ Kidney disease: ____________
Epilepsy/ seizures: ________
Mental illness/ depression: ___________
others: _______________________________________________
Vitamins: _________________ Herbals: ____________________
Street drugs: _________
Alcohol (amount/ frequency): ______________ Tobacco: ______
Smokeless tobacco: ______
Expectations of this hospitalization:
_______________________________________________________
Will admission cause any lifestyle changes (describe):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Evidence of failure to improve: ____________________________
_______________________________________________________
Date of last physical exam: _______________________________
Nursing Diagnosis: _____________________________________
_______________________________________________________
_______________________________________________________
DISCHARGE PLAN CONSIDERATIONS
Projected length of stay: ___________________ Anticipated date of
discharge:_______________
Date information obtained: ___________
Resources available
Persons: _____________________________________________
financial: _____________________________________________
Community support: ___________________________________
Groups: ______________________________________________
Areas that may require alteration/ assistance:
Food preparation: _________________
Shopping: _______________________
Transportation: ___________________
Ambulation: ______________________
Medication/ IV therapy: _____________
Treatments: ______________________
Wound care: ______________________
Supplies: _________________________
Homemaker/ maintenance (specify):
_______________________________________________________
Physical layout of home (specify):
_______________________________________________________
Referrals (date/ source/ services)
Social services: _______________________________________
Rehab services: _______________________________________
Dietary: ______________________________________________
Home care: ___________________________________________
Respiratory/ O2: _______________________________________
Equipment: ___________________________________________
Supplies: _____________________________________________
Other: _______________________________________________
Objective (Exhibits)
Observed response to activity: Unable to tolerate ambulation; radial
pulse increase by 10-15 bpm from basal pulse
Specific activity: Walk (Assuming you let pt walked-IF NOT CONTRA)
GENERAL INFORMATION
Name: Last Name / First Name / Middle Initial
______
Age: _______
Birthdate: MM/DD/YY____________
Address: ______________________________________________
Admission: Date:_____ Time: _________
From: Home: _________________________________________
Hospital: ________________________________________
Others: Ambulance – Paramedics pick-up from home
HEALTH HISTORY
Reason for this visit (chief complaint): “Masaki tang dibdib ko” or
Just plain chest pain, SOB, dizziness, etc.
History of Present Illness: Condition started 2 weeks PTA as
increasing body weakness, limiting performance of household chores,
swelling of ankles & feet late PM, & nocturnal dieresis 60cc X4. 5 days
PTA, felt on and off chest heaviness aggravated by activity, radiating
to left arm, relieved by rest & unrecalled medications. Consulted
family physician who referred her to this institution.
History of Past Surgeries/ Hospitalizations: No previous hospitalization
and surgery of Unremarkable medical/surgical history
Diagnoses/ Impressions: CAD, CKD, DM Type 2
Source of Information: Patient and daughter
Date: 03/30/11
ACTIVITY/ REST
Subjective (Reports)
Occupation: Government employee
Able to participate in usual activities/ hobbies: Yes – but with support
or assistance
Leisure time/ diversional activities: Reading pocket books, watching
Mara Clara
Ambulatory: Yes with assistance or support (Y/N-describe)
Gait (describe): Normal / limp/ unsteady/ loss of balance/fear of falling
(Others: spastic, scissors, steppage, ataxic, parkinsonian)
Activity level (sedentary to very active): sedentary/moderately
active/vigorously active/extremely active
Daily exercise (type): brisk walking
Muscle mass/ tone/ strength (e.g normal, increased, decreased):
_______________________________________________________
_______________________________________________________
History of problems/ limitations imposed by condition (e.g. immobility,
can’t transfer, weakness, breathlessness):
________________________________________________________
________________________________________________________
________________________________________________________
Feelings (e.g. exhaustion, restlessness, can’t concentrate
dissatisfaction): ___________________________________________
________________________________________________________
Sleep: Hours 6 hours
Naps: 20 mins X2/day (10AM/3PM)
Insomnia:Y/N
Type: Initial / terminal / Intermittent
Rested on awakening: Y/N
Excessive grogginess: Y/N
Bedtime rituals: Glass of milk, scented candle bath
Relaxation techniques: yoga, spa, bubble bath
Sleeps on more than one pillow: Y/N # of pillows (due to DOB?)
Oxygen use (type): 4LPM/NC
When used: Continuous
Objective data
Medications/ herbals for/affecting sleep: Y/N- list the medications
________________________________________________________
______________________________________________________
Before Activity
HR – 90
RR – 20
BP – 140/90
Immediately after
100
25
150/100
After 5 minutes
90
20
140/90
Pulse oximetry: 94% at 4LMP/NC (90% Room Air)
Mental status (e.g. cognitive impairment/ withdrawn/ lethargic): LOC’sconscious, lethargic, coherent
Muscle mass/ tone (e.g. normal, flaccid, hypertonic, hypotonic,
spastic, rigid) : Generally firm
Posture (e.g. normal, stooped, curved spine): erect, slumped, tripod
position
Tremors: Y/N Location: describe location of tremores
ROM: Describe: Full ROM in all
extremitites / encircle the joint in the
illustration with problem
_______________________________
_______________________________
_______________________________
Strength: 4/5 in all extremities
Uses Mobility Aid/s: Y/N
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
CIRCULATION
Subjective (Reports)
History of/ Treatment for (date):
High blood pressure: Yes/No ONLY
Head injury: __________________________________________
Stroke: ______________________________________________
Hemoptysis: __________________________________________
Heart Problem/surgery: _________________________________
Syncope: _____________________________________________
Spinal cord injury/ dysreflexia: ____________________________
Palpitations:___________________________________________
Bleeding tendencies’ episodes: ___________________________
Specify: ____________________________________________
Varicosities: __________________________________________
Heart problems/ Surgery: ________________________________
Thrombophlebitis: ______________________________________
Pain in legs with activity: _________________________________
Extremities: Numbness: Y/N Location: Describe location
Tingling: Y/N Location: Describe location
Slow healing wound:
Stages: _______
Site (describe): ______________________________
Medication/herbals: Unrecalled
Objective (Exhibits)
Color:Skin: Sallow Mucous membrane: Pinkish/Brown spots
Lips:Red
Sclera: Dirty
Conjunctiva: Pale
Nailbeds: Thick, whitish
Skin moisture (e.g. dry, diaphoretic): Diaphoretic
Blood pressure: lying:
R: _______ L ___________
Standing:
R: _______ L ___________
Pulse pressure: 140/90
Auscultatory gap: Present after 70 diastolic
Page 1
Pulses: Carotid: 70
Describe: 4+
Temporal:__________
Describe:____________________________________________
Brachial: __________
Describe: ___________________________________________
Radial: ____________
Describe:____________________________________________
Ulnar: _____________
Describe: _____________________________________
Dorsalis pedis: ___________
If dorsalis pedis absent or abnormal,
post tibial_______________________________________
If post-tibial pulse absent or abnormal,
popliteal: ______________________________________
If popliteal pulse absent or abnormal,
femoral: ______________________________________
Cardiac (palpation): thrill Y/N
heaves: Y/N
Heart sounds (auscultation):
Rate:96
Rhythm: Irregular Quality: +2
Friction rub: Y/N
Murmur (describe location/ sounds): Y/N
Vascular bruit (location): Y/N
Jugular vein distention: Yes
Breath sounds: location: Rales, bibasal (Crackles, wheezes, rhonchi)
Description: Coarse / fine
Extremities:
temperature: warm/cold color: pale capillary refill: 1-2 secs
Homan’s sign: Y/N
varicosities (location): Y/N
Nail abnormalities: :Leukonychia, splinter hemorrhage, clubbing
edema(location/ severity +1 to +4): +3, lower extremities, bilateral
Distribution/ quality of hair: Equal (velus & terminal hairs)
Skin lesions: type:Macule, papule, vesicle, bullae, keloid, scar
location: describe the location + size
color: Reddish, necrotic, purplish
Nursing Diagnosis:
________________________________________________________
________________________________________________________
_____________________________________________________
EGO INTEGRITY
Subjective (Reports)
Marital status: Singe, married, separated, widow, complicated?
Expression of concerns (e.g. financial, lifestyle or role changes):
“Walang mag-aalaga sa mga anak ko” / None as of the moment
Stress factors: Workload, supervisor, noise
Usual ways of handling stress: watching TV, spa, yoga
Ways of expressing feelings:
Anger: Break glass, shout at co-workers, be quiet
Anxiety: nail-biting
Fear: go to church, magtago sa ilalim ng bed
Grief: cry, pray
Others (hopelessness, helplessness, powerlessness): pray
Cultural factors/ ethnic ties: Canao
Ethnic group: Kankanaey
Religious affiliation: Roman Catholic
Active/ Practicing: Y/N
Practices (prayer/meditation, etc.): Novena, rosary
Religious/ Spiritual concerns: Anti-RH bill, no to abortion
Desires clergy visit: Y/N
Expression of sense of connectedness/ harmony with self and
others: Prayer meetings, social gatherings, bingo social
Medications/ Herbals: List of medications affecting ego-integrity
Objective (Exhibits)
Emotional status (check those that apply):
Calm: ______ Anxious:_________ Angry: _______________
Withdrawn: __________ Fearful: ______Irritable: __________
Restive: ________ Euphoric: ___________
Observed body language (e.g. pacing, fidgeting): nail-biting, arms
crossed over chest, looks at window and time
Observed physiological response (e.g. pallor, flushing): pallor, sallow
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
ELIMINATION
Subjective (Reports)
Usual bowel elimination pattern: Once a day, before taking bath
Character of stool: Formed Color of stool: Clay
Date of last BM and character of stool: (describe): 03/29/11 – formed
in consistency, yellowish in color, approximately 50cc, malodorous
History of bleeding (describe): Y/N..2 years ago, during defecation,
fresh blood approx 20 cc 3X 2 days – no interventions done
Hemorrhoids/ Fistula: Y/N
Acute: <3 days
Constipation: acute: Y/N chronic: Y/N
Chronic: >3 days
Diarrhea: acute: Y/N chronic: Y/N
Bowel incontinence: Y/N
Laxative: Y/N how often: ________________________
Enema/ suppository: Y/N how often: ______________
Usual voiding pattern and character of urine: once every 4 hours,
approx 100 cc per void, nocturnal dieresis 4X
Difficulty voiding: Y/N
Urgency: Y/N
Bladder spasm: Y/N
Frequency: Once every 4 hours/ 4X
Retention: Y/N
Burning: Y/N
Urinary incontinence (type/ time of day when it usually occurs):
_______________________________________________________
_______________________________________________________
History of kidney/ bladder disease: CKD
Diuretic use: Y/N (Specify drug)
Meds/Herbal: List medications related to elimination taken by patient
Objective (Exhibits)
Abdomen (palpation): Soft/ firm: Soft, smooth, non-tender
Tenderness/pain (quadrant/ location): Pain at RLQ
Distention: Y/N
Palpable mass/ location: Y/N
size/ girth: 35 inches at largest diameter
Abdomen (auscultation):
bowel sounds (location/ type):
Normoactive at regular intervals (15 per quadrant)
Costovertebral Angle tenderness: Y/N
Bladder palpable: Y/N
Hemorrhoids/ fistulas: Y/N
Presence/ use of cathether or continence devices:
Y/N Describe: IFC/Diapers
Ostomy devices (describe appliance and location)
Ileostomy appliance at RLQ
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
FOOD/ FLUID
Subjective (Reports)
Usual food intake:
3 # of meals daily: 2 snacks
(# and time consumed) 10AM/3PM
Dietary pattern/ content:
B: fried rice, eggs, coffee, dried fish
L: rice, nilagang beef/ sinigang pork, pakbet
D: rice, chopsuey, fried fish
Snacks: soda, banana que, chicken sandwich
Last meal consumed/ content: If no food taken X 24 hrs
Food preferences: rice, vegs, pork, beef, chicken
Food allergies/ intolerances: crustaceans (shrimp, lobster, crabs)
Page 2
Cultural or religious food preparation/ concerns/ prohibitions: dinuguan
Usual appetite: consumes 70-80% of food served
or plate wastes
Change in appetite: consumes 40% of food served
Usual weight: 75-80 kg
Unexpected/ undesired weight loss/ gain: 2 kg gained
Nausea/ vomiting: Y/N
Related to: identify precipitating factor
Heartburn: Y/N
Indigestion: Y/N
related to: identify precipitating factor
relieved by: eating , vomiting, medications
Chewing or swallowing problems:
Gag/ swallow reflex present: Y/N
Facial injury/ surgery: Y/N
Stroke/ other neurological deficit: Y/N (Paralysis, impairment of
speech, tremors, dystonia, loss of balance, etc
Diabetes: Y/N- type 1 or type 2
Controlled with diet/pills/insulin: OHA, insulins (identify brand used)
Vitamin/ food supplements: _______________________________
Medication/ herbals: _____________________________________
Objective (Exhibits)
Current weight: in kg or in lbs Height: feet or cm
Body built: endomorph, mesomorph, ectomorph
BMI: underweight, overweight obese
Skin turgor: good or poor
Mucous membranes (moist/ dry): moist or dry, plus color
Edema: generalized: Y/N dependent: Y/N
feet/ ankles: Y/N (grade-1+, 2+, 3+, 4+)
Periorbital: Y/N abdominal/ascites: Y/N + measurement
Breath sounds (location/ adventitious sounds): (data can be written at
respiratory portion page 4)
Condition of teeth/ gums: complete set of teeth, healthy pinkish gums
Dentures (full/partial): Y/N, if yes-complete or partial (# of teeth)
Loose/ absent teeth/ poor dental care: Y/N(identify absent/loose tooth)
sore mouth/ gums: Y/N – identify specific areas
Appearance of tongue: pinkish, symmetrical, no tongue deviation
mucous membranes: moist, pinkish
Abdomen: bowel sounds (quadrant/ location): 20-15 per quadrant
hernia/ masses: Y/N (identify area/location)
Urine S/A or chemstix: Sugar/ Albumin +2
Serum glucose (glucometer): 190 mg/dl
Nursing Diagnosis: ________________________________________
________________________________________________________
________________________________________________________
HYGIENE
Subjective (Reports)
Ability to carry out activities of daily living: independent/ dependent
(level 1= no assistance needed to 4= completely dependent): 2
Mobility: Assistance needed (describe): Y/N
Assistance provided by: daughter, husband (identify SO)
Equipment/ prosthetic devices required: Y/N, cane, walker, etc.
1-no assistance
Feeding: Oral, NGT, PEG Tube
2-remind pt to do it independently
Help with food preparation: Y/N
3-substantial assistance
Help with eating utensils: Y/N
4-completely dependent
Hygiene:
Get supplies: Y/N
Wash body or body parts: Y/N
Can regulate bath water temperature: Y/N22c
Get in and out alone: Y/N
Preferred time of personal care/ bath: 10AM
Dressing: Y/N
Can select clothing and dress self: Y/N
Needs assistance with (describe): daughter / SO
Toileting:
Can get to toilet or commode alone: Y/N
Needs assistance with (describe): Daughter / SO
Objective (Exhibits)
General appearance: Manner of dressing: clean, appropriate to age
and climate, fit to body
Grooming/ Personal habits: appears clean & groomed appropriate for
age and ethnic group
Bath: Y/N
Shampoo Y/N Perineal Care Y/N
Oral Care Y/N`
Condition of hair/ scalp: dry, scaly, brittle hair, healthy hair & scalp
Body odor: Y/N
Use of deodorant: Y/N
Presence of vermin (lice, scabies): Y/N
Nursing Diagnosis: ________________________________________
NEUROSENSORY
Subjective (Reports)
History of brain injury, trauma, stroke (residual effects): Y/N-when?
What interventions was done
Fainting spells/ dizziness: Y/N
Headaches (location/type/frequency): Y/N…temporal, tension,
migraine, once a week after reading
Tingling/ numbness/ weakness (location): Y/N at lower extremities
Seizures: Y/N
History or new onset seizures
Type: grand mal, tonic, clonic, atonic Frequency: Once a year
Aura: Y/N
Postictal state: Y/N , altered state of consciousness
How controlled: medications –identify
Vision:
Loss or changes in vision: Y/N
Date of last exam: March 2000
Glaucoma: Y/N Cataract: Y/N
Eye Surgery (type/ date): LASIK Surgery 2002
Hearing loss: Y/N Sudden or gradual: gradual
Date of last exam: _____________________________________
Sense of smell (changes): Y/N…Anosmia
Sense of taste (changes): Y/N
Epistaxis: Y/N
Other: _______________________________
Objective (Exhibits)
Mental status (note duration of change): Put a check mark
Oriented/ disoriented: √
Person: √
Place: √
Time: √
Situation: or events √
Check all that apply:
Alert: _______ Drowsy: ________ Lethargic: ______________
Stuporous: ______ Comatose: ____Cooperative: _____________
Combative: ___________ Agitated/ restless: _____________
Follows commands: ____________
Delusions (describe): grandeur, jealousy, guilt, persecutory
Hallucinations (describe): visual, auditory, auditory
Affect (describe): flat, blunted
Speech: aphasic, slurred, spontaneous, appropriate use of words
Memory
Recent: able to recall… Remote: able to recall…
Glasgow Coma Scale: 15/15 or (E4, M6, V-Intubated)
Test
Score
EYE OPENING RESPONSE
SCORE
Spontaneously
4
To speech
3
To pain
2
None
1
MOTOR RESPONSE
Obeys
Localizes
Withdraws
Abnormal flexion
Abnormal extension
None
VERBAL RESPONSE
Oriented
Confused
Inappropriate words
Incomprehensible
None
TOTAL SCORE
6
5
4
3
2
1
5
4
3
2
1
15
Page 3
Cranial Nerves Assessment (describe result)
CN 1 : ________________________________________________
CN 2: ________________________________________________
CN 3:_________________________________________________
CN 4: ________________________________________________
CN 5: ________________________________________________
CN 6: ________________________________________________
CN 7: ________________________________________________
CN 8: ________________________________________________
CN 9: ________________________________________________
CN 10: _______________________________________________
CN 11: _______________________________________________
CN 12: _______________________________________________
Wears glasses Y/N Contacts: Y/N
Hearing aids: Y/N
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
PAIN/ DISCOMFORT
Subjective (Reports)
Location: chest
Quality: Heavy
Intensity ( 1,2,3,4,5,6,7,8,9,10 ) 6/10
Mini Mental Status Examination
Folstein Mini Mental Status Examination
Task
Instructions
Date
"Tell me the date?" Ask for
Orientation omitted items
One point each for
year, season, date,
day of week, and
month
Place
"Where are you?" Ask for
Orientation omitted items.
One point each for
state, county, town,
5
building, and floor or
room
5
Register 3
Objects
Name three objects slowly
and clearly. Ask the patient
to repeat them.
One point for each
item correctly
repeated
3
Serial
Sevens
Ask the patient to count
backwards from 100 by 7.
Stop after five answers. (Or
ask them to spell "world"
backwards.)
One point for each
correct answer (or
letter)
5
Recall 3
Objects
Ask the patient to recall the
objects mentioned above.
One point for each
item correctly
remembered
3
Naming
Point to your watch and ask
the patient "what is this?"
Repeat with a pencil.
One point for each
correct answer
2
Repeating
a Phrase
Ask the patient to say "no ifs, One point if
1
ands, or buts."
successful on first try
Give the patient a plain piece
of paper and say "Take this
Verbal
One point for each
paper in your right hand, fold
Commands
correct action
it in half, and put it on the
floor."
3
Show the patient a piece of
Written
paper with "CLOSE YOUR
Commands
EYES" printed on it.
1
Writing
Drawing
Scoring
Ask the patient to write a
sentence.
Radiation: left arm
Frequency: on & off
Precipitating factors: activity
Relieving factors : Pharmacologic: Unrecalled
Non-pharmacologic (e.g rubbing, rest, herbal): rest
Associated symptoms: swelling of lower extremities, sweating
Effect on: Daily activities: unable to do ADL’s
Relationships: No sexual activity, always fighting
Job: absenteeism
Enjoyment of life: limited to watching TV
Objective (Exhibits)
Grimacing: Y/N
Guarding affected area: Y/N
Narrowed focus: Y/N
Emotional response (e.g crying, withdrawn, anger): Sad
Vital sign changes (acute pain): BP: ________ PR: ________
RR: _________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
Scoring
One point if the
patient's eyes close
One point if sentence
has a subject, a verb, 1
and makes sense
One point if the
figure has ten
corners and two
Ask the patient to copy a pair intersecting lines
of intersecting pentagons
onto a piece of paper.
A score of 24 or above is considered normal.
1
30
Deep tendon reflexes (present/ absent): ________
(encircle joint with abonormal reflex, then rate)
Tremors: ________ Paralysis (R/L): _________
Posturing: _____________________________________________
RESPIRATION
Subjective (Reports)
Dyspnea related to: Orthopnea, exertion
Precipitating factors: Activity Relieving factors: Rest
Cough (describe): productive, non-pro, able or unable to expectorate
sputum (describe character): rusty, approx 10cc per expectoration
Requires suctioning Y/N
History of (year): bronchitis: √
asthma: √
emphysema: ____tuberculosis: __recurrent pneumonia: ______
exposure to noxious fumes/ allergens: ___
Infectious agents/ diseases/ poisons/ pesticides:
_______________________________________________________
Smoker: Yes: ___ No: ___
Type (e.g. menthol) ________ sticks/packs per day: ________
No. of Yrs: ____________
Use of respiratory aids: oxygen, nebulizers, ventilators, etc
Oxygen (type/ frequency): 4LPM / NC, FM, Non-rebreather, ect
Medications/ herbals: ______________________________________
_______________________________________________________
_______________________________________________________
Objective (Exhibits)
Respirations
Spontaneous: Rate: 96
Depth: deep
Assisted: Y/N Parameters: _______________________________
_____________________________________________________
O2 inhalation: Y/N Type: NC, FN, Non-rebreather
Flow Rate: ____________________________________________
Chest excursion (equal/ unequal): symmterical
Fremitus: buzzing at ulnar aspect of hand, more pronounced at..
Use of accessory muscles: Y/N…SCM, Scalene, trapezius
Nasal flaring: Y/N
Breath sounds: wheezes, rales, crackes, stridor
Egophony:muffled: Y/N
clear: Y/N
Skin/ mucous membrane color: Pinkish
clubbing of fingers: Y/N
Sputum characteristics: Yellowish-copious
Pulse oximetry: 94% at 4LPM/NC
Page 4
Mentation (e.g. calm, anxious, restless): calm, oriented to time, place,
person
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
SAFETY
Subjective (Reports)
Allergies/ sensitivity (medications, foods, environment, latex):
crustaceans, penicillin, laundry powder
Type of reaction: generalized rashes
_______________________________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
chicken pox, measles, mumps
Exposure to pollution, toxins, poisons/ pesticides, radiation
(describe reactions): Y/N – pesticides used by a farmer father
Living conditions (with whom/ location of residence): living with
daughter at a subdivision but near garbage pumping site
Travelled Places: Palawan, India
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
Put a check
mark/doses
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify): ______________________________________
Altered/ suppressed immune system (list cause): taking
corticosteroids, or anti-rejection drugs, anti-cancer drugs, etc
History of STD (date/ type): gonorrhoea 1998
test: VDRL test 1998
High risk behaviours: sexually active during prime of her life
Blood transfusion/ number: ___________ Type: _____________
Date: ______________________________
Reaction (describe): ___________________________________
_____________________________________________________
Use seat belt regularly: ____Bike helmets: ______
Other safety devices: ____________________________________
Work place safety/ health issues (describe): prolonged sitting, office at
3rdfloor, rest room at ground floor
Currently working: Y/N
Rate working conditions (e.g. safety, noise, heating, water,
ventilation): scale of 1-10, 5 in terms of above mentioned factors
History of accidental injuries: fall, 2005 due to wet floor
Skin problems (e.g. rashes, lesions, moles, breast lumps, enlarged
nodes) describe: petechiae at forearms and legs
Delayed healing (describe): Y/N … a lesion at right big toe due to
pedicure 2009, 6 months healing process
Cognitive limitations (e.g. disorientation, confusion): Y/N, describe
(Front)
(Back)
Results of testing (e.g. cultures, immune function, TB, hepatitis):
Laboratory results here…
Nursing Diagnosis: _____________________________________
_______________________________________________________
SEXUALITY (Component of Social Interaction)
Subjective (Reports)
Sexually active: Y/N
STI/ Birth control method: Y/N (describe)
Sexual concerns/ difficulties (e.g. pain, relationship, role): Y/N
describe
Recent change in frequency/ interest: loss of libido
FEMALE: Subjective (Reports)
Menstruation
Age at menarche: 9 years old__________________
Length of cycle: 28 days regular____________________
Duration: 4 days __________________________
Number of pads/ tampons used/ day: 3 pads/ moderately
soaked/day_________________________________
Last menstrual period: April 11, 2011_______________
Bleeding between periods: Y/N ____________
Reproductive Infertility concerns: None______________________
Type of therapy (hormones): None___________________________
Pregnant now: Y/N________ G: 3___ P: 2___ (TPAL): 2-0-0-2____
EDD: January 18 2012__________________________________
History of Present Condition: (Start, list and describe symptoms
chronologically from time/day of onset onwards)
Initial: Wt: 75 kg________
Vital signs: BP=120/80 mmHg HR= 80 beats/mn RR= 12 cycles/min
Temp. 37.5 C_______
Age of Gestation:20 weeks _______________
Labor
1.Abdominal Status: FU:20 cm ___ EFW: 50 grams________
AOG: 22 weeks ___
a) Presence of uterine contraction:
frequency
duration
interval
intensity
None as of
None as of
None as of
None as of
moment
moment
moment
moment
Every ___
60-90 seconds 1 minute
Mildminutes
moderatesevere
b) IE Result:
Sensory limitations (e.g. impaired vision/ hearing, detecting hot/cold,
taste. Smell, touch):_______________________________________
_______________________________________________________
Prostheses: Y/N Ambulatory devices: crutches, cane
Violence (episodes/ tendencies): Y/N
Objective (Exhibits)
Body temperature:37 °C
Skin integrity (e.g. scars, rashes, ulcerations, ulcerations, bruises,
blisters, burns – degree/ %, drainage) / mark location on diagram:
_______________________________________________________
time
Dilat’n
Efface’t
BOW
Cond.
station
discharges
Done By
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Past Medical History
a.) Includes childhood illnesses (mumps, measles, german
measles, poliomyelitis, etc)german measles, varicella
______________________________________________
______________________________________________
Page 5
b) Any previous health care contacts- Include diagnostic test
results and date : u/a, cbc, bld. Typing, glucose screening
test, utz result: laboratory results here…
c) Allergy- include food and drug hypersensitivity: Y/N describe
d) Use of OTC/prescribed drugs: Paracetamol, Decolgen, etc
e) Past pregnancies:
No. Of
Preg.
Yr
Method
of Del.
Place of
del./attended
by
Birth
wt
Cond’n
Condn of
baby
1
1986
NSVD
Home/
midwife
2.6
kg
Hospital/
physician
1.8
kg
Tolera
ted
labor
and
deliver
y
Arrest
in
labor
thus
CS
Adapte
d to
extraute
rine
environ
ment
Adapte
d to
extraute
rine
environ
ment
1
1990
LSCS
Prenatal History
d1) General physical and emotional state of the mother during
pregnancy: observed expected physiologic changes of
pregnancy , planned and accepted pregnancy, ______
__________________________________________________
d2) Prenatal check up/consultations:
1st trimester (frequency): once_________________________
Diagnostic & result: VDRL –negative resul, CBC- Hgb =8
g/dL, Blood type= B(+) Rh (-)_____________
2nd trimester:once _________________________________
Diagnostic & result: ultrasonography=singleton, male,..____
3rd trimester: no prenatal_____________________________
Diagnostic & result: none__________________________
d3) Pregnancy complications & discomforts during present
pregnancy(if any)- nausea and vomiting: Y/N_______________
loss of appetite: Y/N ____ edema: Y/N _____ UTI : Y/N _____
co morbid illness: hypertension,...______ Vag’l bleeding: Y/N
abnormal weight change: Y/N ______ HPN: Y/N _______
d4) Was pregnancy planned: Yes: ______ No: ______
when was quickening felt: 5 months gestation_____________
attitude of father: accepted pregnancy, supportive___________
place where mother plans to give birth: birthing facility/home
_________________________________________________
Gynecologic History (Date):
a.) Surgery affecting the: breast: Y/N _____ Mastectomy: Y/N ____
hysterectomy: Y/N ___ Hysterectomy: Y/N ___ TAHBSO : Y/N
b.) Ectopic pregnancy: Y/N _______
c.) Reproductive tract diseases: PID: Y/N ______
Polycystic ovarian disease: Y/N ______ H-mole : Y/N _____
Others: specify: STI__________________________________
d.)Breast:(symmetrical):symmetrical/assymetrical ______
size and shape ______ retractions/ dimpling: Y/N ______
nipple discharge: Y/N _______ redness of the skin: Y/N
_____ visible superficial veins: Y/N _____ lumps or masses
on both breasts: Y/N _______ axillary lymph node mass:
Y/N _____ tenderness: Y/N __________
d.) Abdomen: (minimal) gravidarum striae: Y/N _______
(protruded) umbilicus Y/N ______ fundic height 20 cm :
__________ tenderness: Y/N _______ (occasional/mild)
uterine contractions: (frequency /intensity/interval/duration)
________ fetal movement 10-12 ./ hour______________
bowel sounds:
no. per minute
25
*Leopold’s Maneuver:findings: describe:
LM I: round firm parts ______________________________
_______________________________________________
_______________________________________________
LM II: left: smooth flat, right: nodular prominences,
longitudinal lie, FHT site at LUQ______________________
_______________________________________________
LM III: irregular , soft parts__________________________
_______________________________________________
_______________________________________________
LM IV: engaged/ ballotable,/ completely flexed, partially
flexed, extended, military attitude _________________________
_______________________________________________
_______________________________________________
e.) Genitourinary tract:
(Darkly pigmented) inguinal region: Y/N _________________
vaginal secretions (watery or bloody): Y/N _______________
presence of haemorrhoids: Y/N ______________________
f.) Extremities: symmetrical length: Y/N _____________________
size upper and lower extremities: ___________________
edema: Y/N _ varicosity: Y/N __ limitation of ROM Y/N ____
swelling of joints: Y/N ______ peripheral pulses: _______
tenderness: Y/N ______ claudication: Y/N ___________
g.) Integumentary: gravidarum striae-: Y/N ____________________
specify location: abdomen______ lesions: ____ rashes: ___
hematoma/petechiae: Y/N _____ chloasma: Y/N _______
Post Partum
h.) Abdominal status:
location and size of the uterus: 1 cm below umbilicus,_______
condition of the uterus: soft boggy_______________________
i.)GUT status: presence of vaginal discharge: Y/N _________
amount: 4 fully soaked pads in 2 hours___ color: bright red___
condition of the perineum ( particularly if episiotomy is done):
eryhtematous, ecchymosed, approximately 5 cm on the RML
area ______________________________________________
functioning of the bladder (time and amount of first urine, time
of first BM postpartum) urine 250 mL 2 hours after delivery,
bowel movement after 8 hours of delivery _______________
_________________________________________________
j.) Emotional/ Psychological Status
postpartum blues: Y/N ________ depression: Y/N __________
heightened emotional reactions/labile moods: Y/N _________
_________________________________________________
Menopause: Y/N _____ onset: 55____________
Hysterectomy/ Oophorectomy: Y/N _________________________
Problem with: Vaginal lubrication: Y/N _____ hot flushes: Y/N _____
Vaginal discharge: Y/N ______ others: ____________________
Hormonal therapies: Y/N ________________________________
Osteoporosis medications: Y/N ____________________________
Practices BSE: Y/N ____ Last mammogram: date _______________
Last Pap smear: date_________ Results: ______________________
Objective (Exhibits)
Genitalia (warts/ lesions): none_______
STI test results: _________________________________________
vaginal bleeding/ discharge: ________
Management: Meds: prescribed:___________________________
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
MALE: Subjective (Reports)
Circumcised: Y/N
Practices self examination: Breast: Y/N
testicles: Y/N
Prostate disorder: Y/N
last prostocopic/ prostate exam: January 2008
last PSA date: Y/N (Prostate specific antigen test)
Medications/ herbals: ____________________________________
Objective (Exhibits)
Genitalia: Penis (circumcised): Y/N warts/ lesions: Y/N
bleeding/ discharge: Y/N Testicles (e.g. lumps): Y/N
Breast examination: Y/N
STI test results: __________________________________________
_______________________________________________________
Nursing Diagnosis: _______________________________________
_______________________________________________________
_______________________________________________________
Page 6
SOCIAL INTERACTIONS
Put a check mark
Subjective (Reports)
Relationship status:
Single: _____ Married: _______
Separated/ Annulled/ Divorced: ________ Widowed: ______
Living with (Specify): ____________________________________
Yrs of Relationship:__________
Perception of relationship: happy living alone
Concerns/ stresses: no one to talk to when sad
Role within family structure: breadwinner
Number/ Age of children: __________________
Perception of relationship with family members: happy being the lone
provider to the needs of children
Extended family: Y/N
other support persons: __________________________________
Ethnic/ Cultural affiliations: _______________________________
Strength of ethnic identity: _______________________________
Feelings of (describe):
Mistrust: Y/N
Rejection: Y/N
Unhappiness: Y/N, sometimes, seldom, rare
Loneliness/ Isolation: Y/N
Problems related to illness/ condition: Unable to work
Problems with communication (e.g. speech, another language, brain
injury): ______________________________________________
Use of speech/ communication (list)_______________________
____________________________________________________
Is interpreter needed:Yes ______ No ______
Primary language: _________________________
Objective (Exhibits)
Communication/ speech: Clear: ______ Slurred: _______
Unintelligible: _____ Aphasic: ______
Put a check mark
Unusual speech pattern/ impairment: _____
Laryngectomy present: _____
Family interaction (behavioural pattern): open communication to
children, free to express their emotions
Nursing Diagnosis: _____________________________________
________________________________________________________
______________________________________________________
TEACHING/ LEARNING
Subjective (Reports)
Communication Dominant Language (specify):
_______________________________________________________
Second language: _______________________________________
Literate (reading/ writing): ______________
Educational level: _____________________________________
Learning disabilities (specify): ___________________________
Cognitive limitations: ____________________________________
Ethnic Affiliation: __________________________
Health and illness beliefs/practices/ customs: _______________
_______________________________________________________
Which family member makes healthcare decisions/ is spokesperson
for client: _________________________________
Presence of Advanced directives: _______ Code status: _______
Durable medical power of attorney: ___________
Designee: ____________________________________________
Health goals: ___________________________________________
Current health problem: client understanding of problem:
________________________________________________________
______________________________________________________
Special health concerns (e.g. impact of religious/ cultural practices):
_____________________________________________
_______________________________________________________
Familial risk factors (indicate relationship):
Diabetes: _____________ Thyroid (specify): ____________
Tuberculosis: ____________ Heart disease: __________
Stroke: __________________ Hypertension: ____________
Cancer: ________________ Kidney disease: ____________
Epilepsy/ seizures: ________
Mental illness/ depression: ___________
others: _______________________________________________
Vitamins: _________________ Herbals: ____________________
Street drugs: _________
Alcohol (amount/ frequency): ______________ Tobacco: ______
Smokeless tobacco: ______
Expectations of this hospitalization:
_______________________________________________________
Will admission cause any lifestyle changes (describe):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Evidence of failure to improve: ____________________________
_______________________________________________________
Date of last physical exam: _______________________________
Nursing Diagnosis: _____________________________________
_______________________________________________________
_______________________________________________________
DISCHARGE PLAN CONSIDERATIONS
Projected length of stay: ___________________ Anticipated date of
discharge:_______________
Date information obtained: ___________
Resources available
Persons: _____________________________________________
financial: _____________________________________________
Community support: ___________________________________
Groups: ______________________________________________
Areas that may require alteration/ assistance:
Food preparation: _________________
Shopping: _______________________
Transportation: ___________________
Ambulation: ______________________
Medication/ IV therapy: _____________
Treatments: ______________________
Wound care: ______________________
Supplies: _________________________
Homemaker/ maintenance (specify):
_______________________________________________________
Physical layout of home (specify):
_______________________________________________________
Referrals (date/ source/ services)
Social services: _______________________________________
Rehab services: _______________________________________
Dietary: ______________________________________________
Home care: ___________________________________________
Respiratory/ O2: _______________________________________
Equipment: ___________________________________________
Supplies: _____________________________________________
Other: _______________________________________________
