Inter American University of Puerto Rico

Metropolitan Campus
Science and Technology Faculty
Carmen Torres de Tiburcio School of Nursing
Nursing Assessment form
Clients name __________________________________

Students name ____________________________________________________

Objective Data

Subjective Data

*Health perception- health management pattern*

Date of birth ______________________ Ethnic background_________________________
Religion _________________________ Age _________ Sex________________________
Education level_____________________________________________________________
Past treatments_____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Previous hospitalizations _____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Health episode during this year (or previously) ____________________________________
__________________________________________________________________________
Actions taken when the symptoms appear: _______________________________________
__________________________________________________________________________
Obtained results: ___________________________________________________________
__________________________________________________________________________
Reasons to searching health care services________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Medical diagnosis________________________________________________________
__________________________________________________________________________
Current treatment ___________________________________________________________
__________________________________________________________________________

Medical diagnosis ___________________________________________________________

__________________________________________________________
__________________________________________________________

Medication taken now

Name

Dosage

Use

2
Objective Data

Subjective Data
Laboratory results:

Medication taken now

Name

Dosage

CBC
Use

Indicators

Clients results

Normal values

Hemoglobin
Hematocrit
RBC
WBC
Platelets

U/A
Indicators

Clients results

Normal values

Color
Turbidity
How healthy is the client ( circle)

1
Poor

2
Regular

3
Excellent

Health perception (description of health state) _________________________________

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Effect of the disease on
ADL__________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Use of : Alcohol_________________________________________________________
Tobacco ________________________________________________________
Drugs _________________________________________________________
Particular health habits:
Use of medication in the home ______________________________________
__________________________________________________________________
Activities done to maintain a healthy body ____________________________________
_________________________________________________________________
__________________________________________________________________

pH
Specific gravity
Protein
Glucose
Ketones
Microscopic
examination
RBC
WBC
Bacteria/yeast

See page 1084 (Cravens FUNDAMENTALS OF NURSING textbook).

3
Objective Data

Subjective Data
Home remedies used____________________________________________________
__________________________________________________________________
__________________________________________________________________
Last immunizations______________________________________________________
______________________________________________________________________
Do you comply with the prescribed treatment: Yes_____________ No ______________
Difficulty to follow the therapeutic treatment___________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Other laboratory results:

Indicators

Clients results

Normal values

*Activity-exercise health pattern*

Daily activities: (use the code)
Hygiene ______________________________________________________________
Cooking_______________________________________________________________
Bathing ______________________________________________________________
Movement____________________________________________________________
Dressing ______________________________________________________________
Doing shopping ________________________________________________________
Doing house chores _____________________________________________________
Working in the yard _____________________________________________________
Time to eat ____________________________________________________________
Moving in the bed_______________________________________________________
Combing your hair ______________________________________________________
Applying makeup _______________________________________________________
Cleaning the house_____________________________________________________
Disnea________________________ Palpitations____________________________
Chest pain ________________ Weakness __________________________________
Body pain _______ Location of the pain ___________________________________
Describe the pain:
Location_________________________________________________________
Intensity _________________________________________________________
Irradiacin _________________________________________________________
Relief ____________________________________________________________
Duration_________________________________________________________
Description _____________________________________________
Difficulty/rigidity when moving ___________________________________________
______________________________________________________________________

Cardio-respiratory system:
Peripheral pulses:
Carotid _______________________________________________________________
_______________________________________________________________________
Radial _________________________________________________________________
_______________________________________________________________________
Brachial ________________________________________________________________
_______________________________________________________________________
Popliteal ______________________________________________________________
_______________________________________________________________________
Femoral ________________________________________________________________
_______________________________________________________________________
Pedal __________________________________________________________________
______________________________________________________________
Tibial posterior___________________________________________________________
_______________________________________________________________________
Apical pulse ______________________________________________________________
_______________________________________________________________________
Respiratory system:
R.________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Symmetry of thoracic movement________________________________________________
_________________________________________________________________________
Retractions _______________________________________________________________
Sensibility to the touch ______________________________________________________

4
Subjective Data

Objective Data

Resting activities (hobbies)________________________________________________

______________________________________________________________________
______________________________________________________________________
Exercise routine _____________________________________________________
______________________________________________________________________
Occupation ___________________________________________________________
______________________________________________________________________
______________________________________________________________________
What effect has the disease had on the activities of daily living (ADL)_______________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Breaths with his/her mouth open ____________________

Searches for a good position to breath _______________`
Describes sounds produced when breathing ______________________________________
Cough present_____________________________________________________________
Productive cough ___________________________________________________________
Blood Pressure
Sitting
R_____________________________
Laying down R_____________________________
Standing
R _____________________________

L_________________________
L_________________________
L ________________________

Musculoesqueletal:
Posture __________________________________________________________________
Alignment _______________________________________________________________
________________________________________________________________________
Simmetry_________________________________________________________________
________________________________________________________________________
Way of walking ___________________________________________________________
________________________________________________________________________
Balance _________________________________________________________________
_________________________________________________________________________
Coordinated movements ___________________________________________________
________________________________________________________________________
ROM ___________________________________________________________________
________________________________________________________________________
In the following diagram circle the area with limited movement

5
Objective Data

Subjective Data

*Nutritional-metabolic health pattern*

Daily consumption of food and liquids (Take the nutritional history of 24 hours)
Breakfast _____________________________________________________________
______________________________________________________________
Lunch________________________________________________________________
______________________________________________________________
Dinner _____________________________________________________________
_______________________________________________________________
Snacks ______________________________________________________________
_______________________________________________________________
Consumption of liquids ___________________________________________________
Nutrional supplements consumed ___________________________________________
_____________________________________________________________________
Food intolerance ________________________________________________________
______________________________________________________________________
Foods you do not like ____________________________________________________
______________________________________________________________________
Difficulty to chew ________________________________________________________
Disphagia ( difficulty to swallow) ___________________________________________
Problems with the gums __________________________________________________
______________________________________________________________________
Problems with the tongue _________________________________________________
Dental problems ________________________________________________________
______________________________________________________________________
Others problems when eating al ___________________________________________
Have you lost weight: Yes ____ No___ Have you gained weight: Si _____ No ______
How much?__________ Difficulty in gaining weight _____________________________
Difficulty in losing weight _________________________________________________
Description of the appetite _______________________________________________
______________________________________________________________________
Nausea and vomiting ____________________________________________________
Abdominal pain ________________________________________________________
Use of antacids ________________________________________________________
Use of laxatives ________________________________________________________
Problems with the
skin__________________________________________________________________
_____________________________________________________________________
Wound healing _________________________________________________________
Problems with the hair____________________________________________________
______________________________________________________________________
Problems with the nails ___________________________________________________
Intolerance to cold and heat _______________________________________________
_____________________________________________________________________

Appearance_________________________________________________________________
__________________________________________________________________________
Personal care ____________________________________________________________
__________________________________________________________________________
Posture____________________________________________________________________
Facial expression___________________________________________________________
_________________________________________________________________________
Temperature ______________________________________________________________
Skin: Color__________________________________________________________________
Texture ________________________________________________________________
Temperature ____________________________________________________________
Humidity _____________________________________________________________
Turgor _________________________________________________________________
Sensibility to the touch____________________________________________________
Red areas: Circle the affected area in the following diagram

Hair: Color _________________________________________________________________

Amount ________________________ Texture_______________________________
Distribution____________________________________________________________
Nails: Color ______________________ Condition _________________________________
Texture ______________________________________________________________
Mouth: Condition of the oral mucosa____________________________________________
_____________________________________________________________________
# of teeth _____________ Cavities ___________________________________
Absent teeth _______________ (Mark in the following diagram)
Top
*
Bottom *

6
Objective Data

Subjective Data
Changes in the voice ____________________________________________________
Difficulty with strength or vigor______________________________________________
_____________________________________________________________________

Teeth condition__________________________________________________
_____________________________________________________________________
Gums________________________________________________________________
_____________________________________________________________________
Tongue ______________________________________________________________
_____________________________________________________________________

*Elimination health pattern*

Fecal elimination habits:
Frequency ____________________ Color ___________________________________
Odor __________________________Consistency_____________________________
Form________________________________________ Pain____________________
Cosntipation___________________________________________________________
Use of enemas _________________________________________________________
Use of suppositories______________________________________________________
Use of laxatives ________________________________________________________
Stool softener __________________________________________________________
Constant or frequent diarrhea ___________________Odor_______________________
Medication used for diarrhea _____________________________________________
______________________________________________________________________
Ileostomy________________________
Colostomy ______________________
Urinary elimination habits:
Frequency ______________________ Amount _______________________________
Color ________________________ Odor ___________________________________
Pain _______________________ Incontinency _______________________________
Nocturia _____________________ Retention ________________________________
Enuresis ______________________ Hematuria _______________________________
Urgency_________________________ Frequency___________________________
Difficulty when urinating __________________________________________________
Urinary deviation______________________________________________________
Infections_____________________________________________________________
Catheter (Foley) ___________Type_________________________________________
Excessive perspiration: Yes ______ No _____ In which circumstance? _____________
_____________________________________________________________________
Problems with bad breath ________________________________________________
_____________________________________________________________________
Use of diuretics ________________________________________________________

Abdomen :
Contour __________________________________________________________________
Belly button ________________________________________________________________
Pronounced veins__________________________________________________________
Anus:
Rashes ____________________________________________________________________
Lesions ___________________________________________________________________
Sensitive to the touch _______________________________________________________
Miccions:
Amount ____________________
Color ____________________________
Odor ____________________________________ Pain _______________________
Additional description:_________________________________________________________
_________________________________________________________________________
Hematuria __________________________________________________________________
Piuria ________________ Oliguria ______________________________________________
Urinary deviations ___________________________________________________________
Defecation:
Color ______________________________________________________________________
Odor _______________ Consistency ____________________________________________
Form _____________________________________________________________________
Pain______________________________________________________________________
Constipation _______________________________________________________________
Bleeding (Dark stools ________________________________________________________
Diarrhea ______________________________________
Odor_________________________
Medication used for diarrhea
____________________________________________________
__________________________________________________________________________
Ileostomy __________________________Colostomy _______________________________
Medication used for constipation__________ ______________________________________
Laboratories:
Indicators
Clients results
Normal values

7
Objective Data

Subjective Data
* Sleep-rest health pattern*
Hours of sleep ____________ Quality ______________________________________
Expresses not having slept well _____________________________________________
Expresses being tired ____________________________________________________
Difficulty in falling asleep en _______________________________________________
Difficulty in staying asleep______ ___________________________________________
Awake early in the morning Yes ______ No ______
Difficulty in falling to sleep again Yes _______ No _________
Help to fall asleep ______________________________________________________
Medications used to fall asleep ____________________________________________
Nightmares ________________________________________________________
Do you wake up early _____________________________________________
Do you take a nap? Yes_____ No____ Frequency ___________ Duration_______

Appearance : Bags under the eyes _____ Yawning ____ Sleepy ________
Do your eyes close? ____________ Do you fall asleep while talking? _________________
Looks tired _________________________________________________________
Slow to respond:_________________________________________________________
Difficulty in finding the right words ______________________________________________
Irritability ____________ Bad temper ________________ Low tolerance point __________
Short attention span__________________________________________________________
Sleepy _________________________________________________________________
Impaired concentration ______________________________________________________

*Cognitive-perceptual health pattern*

Perception of:
Vision:
Difficulty with vision______________________________________________________
______________________________________________________________________
Visual aids : Glasses _____ Contact lenses______ Others ______________
______________________________________________________________________
Eye surgery________________________________________________________
Tears ____________________________ Hot_____________________________
Secretions ___________________________________________________________
Last visit to the ophthalmologist_____________________________________________
Hearing:
Difficulty in hearing____________________________________________________
Right ear: Deafness : _________ Secretions______________________________
______________________________________________________________________
Pain _________________________________________________________________
Left ear: Deafness __________Secretions ______________________________
______________________ Pain ___________________________________________
Hearing aids________________________________________________________
Ear surgery ________________________________________________________
Taste :
Difficulty with tasting foods_________________________________________________
Smell:
Difficulty with smell_______________________________________________________
Sensation on the skin:
Difficulty with sensation on the skin __________________________________________
Sensitivity to the touch ___________________________________________________
Loss of sensation ____________________________________________________
Pain _________________________________________________________________

Use of glasses /visual aids______________________________________________

Secretions _________________________________________________________
Use de hearing aids _________________________________________________________
Secretions ________________________________________________________
Smell test _____________________________________________________________
Taste test _____________________________________________________________
Reaction to the changes in temperature __________________________________________
__________________________________________________________________________
Lost of sensation ________________________________________________________
Sensitive to the touch Yes _________ No _________ Location ______________________
__________________________________________________________________________
Scale of pain ______________________________________

Facial expression of pain: _____________________________________________________

__________________________________________________________________________
Corporal expression of pain: ___________________________________________________
Characteristics of the pain: _____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

8
Objective Data

Subjective Data
Location _______________________________________________________
Intensity _________________________________________________________
Iradiation _________________________________________________________
Relief ____________________________________________________________
Duration _________________________________________________________
Description _______________________________________________________
Understanding of the disease__ ____________________________________________
______________________________________________________________________
Understanding of the treatment _____________________________________________
______________________________________________________________________
Ability to express him/herself ______________________________________________
______________________________________________________________________
Recent changes in memory ________________________________________________
______________________________________________________________________
Ability to remember :
Past ___________________________________________________________
Present __________________________________________________________
Ability to make decisions_____ ___________________________________________
______________________________________________________________________
Expression of feelings ________________________________________________
______________________________________________________________________
Method of learning : Listening _________________ Reading __________________
Observing ___________

Thinking process:
Alert ___________________________________________________________________
Conscious _______________________________________________________________
Coherent ________________________________________________________________
Orientation: Person ____________ Time __________ Place _____________________
Understanding of the disease ________________________________________________
__________________________________________________________________________
Understanding of the treatment ________________________________________________
__________________________________________________________________________
Ability to express him/herself ___________________________________________________
__________________________________________________________________________
Ability to remember :
Recent________________________________________________________________
Past ________________________________________________________________
Ability to make decisions _____________________________________________________
__________________________________________________________________________
Expression of feelings ____________________________________________________
Reads ____________________________________________________________________

*PATTERN OF BELIEFS AND VALUES*

Orientation of cultural values:
Orientation
PersonControl
nature
Control
Order
Plans
Time
Future
Management
Achievement
Investigation
Relationships
Individual
Independence

Activities

Competition
Success
DO

Associated values
Subdued
Fatality
Fears
Survival
Present
Wonder
Flexibility
Pleasure of the senses
Collateral
Mutual responsibility
Belonging
BE

Harmony
Equilibrium
Balance
Integration
Past
Tradition
Ritual
Obligation
Linear
Authority
Discipline
Hierarchy
Becoming

Religious artifacts present ____________________________________________________

__________________________________________________________________________
__________________________________________________________________________
Particular items present ____________________________________________
__________________________________________________________________________
__________________________________________________________________________
Religious activities ________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Visits from the clergy ________________________________________________________
__________________________________________________________________________
Visits from other groups of people______________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

9
Objective Data

Subjective Data
Productivity

Being oneself

Efficiency
Earning
money

Eloquence
Celebration

Selfactualization
Total
Search /
meaning

Other values: Education ___________ Participate in religious activities ____________

Exercise __________________ Socialization __________________________
Other values ____________________________________________________
____________________________________________________________
Goals _________________________________________________________________
______________________________________________________________________
Source of hope / strengths_________________________________________________
______________________________________________________________________
______________________________________________________________________
Significant religious people in your life ______________________________________
______________________________________________________________________
______________________________________________________________________
Religious practices ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Cultural assessment:
Language __________________________________________________________
Religion _______________________________________________________
Relationship with God ___________________________________________________
____________________________________________________________________`
Individual preferences ______________________________
Touch _____________________________________________
People ( quantity, sex y civil status) permitted during the process of the
disease __________________________________________
Clothes ____________________________________________________
Food and liquids___________________________________________
Activity during the disease _____________________________
Position ________________________________________________
Privacy_______________________________________________

__________________________________________________________________________
Food _________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Clothing __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Lighting ____________________________________________________________________
__________________________________________________________________________
Temperature of the area ____________________________________________________
__________________________________________________________________________

Taken by __________________________________________________________________________________

Bibliography: Example of a Health Assessment Form Organized By Functional Health Patterns.

From Weber, J. (1992). Nurses Handbook Of Health Assessment, 2nd ed. Philadelphia: J. B. Lippincott.
A.Piazza y C. Padilla / Febrero 2003. Rev. 2008
Translated to English (2nd time) by R. Camacho // SEP 2008