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PERSON ASSESSMENT

DATE: DATE:
PRE ASSESSMENT PATHOPHYSIOLOGIC BASIS POST ASSESSMENT PATHOPHYSIOLOGIC BASIS
TYPE OF FAMILY:

SIGNIFICANT OTHERS:

COPING MECHANISM:
P
S RELIGION:
Y
C
H
O DIALECT:
S
O PRIMARY SOURCE OF HEALTH:
C
I FINANCIAL RESOURCES:
A
L
GENERAL APPEARANCE:

GCS SCORE:
Motor response 6 Obeys commands fully
5 Localizes to noxious
stimuli
4 Withdraws from noxious
Verbal response stimuli
3 Abnormal flexion, i.e.
decorticate posturing
2 Extensor response, i.e.
Eye opening decerebrate posturing
1 No response

5 Alert and Oriented


4 Confused, yet coherent,
INTERPRETATION OF speech
SYMPTOMS: 3 Inappropriate words and
jumbled phrases consisting of
words
2 Incomprehensible sounds
1 No sounds

4 Spontaneous eye opening


3 Eyes open to speech
2 Eyes open to pain
1 No eye opening

AFFECT:

ORIENTATION: (TIME, PLACE AND Question:


Well-oriented PERSON) Well-oriented
Question: Anong oras
po kayo nag-umpisa
mag-labor?
SPEECH:
Rate Normal?
Volume Soft?
Fluency and Rhythm
Clear?

NON-VERBAL BEHAVIORS:
Shaking of head She shakes her head Smiling She smiles and nods whenever she agrees to what
whenever she agrees Nodding the student nurse say.
Facial Grimace with poor to what the student
eye contact nurse says.
Due to backpain

STOOL: Pattern:
E Pattern: Consistency:
L Consistency: Color:
I Color: Frequency:
M
Frequency: Quantity:
I
N Quantity: Contour:
A Contour: Abdominal Girt:
T Abdominal Girt:
I
O URINE: Frequency:
N Frequency: Color:
Color: Specific Gravity:
Specific Gravity: Clarity:
Clarity: Clarity:
Quantity: Quantity:
Contraption: Contraption:

CURRENT ACTIVITY LEVEL: ADLs:


Bathing Bathing
0 Total independence
Dressing 1 Assist with device Dressing
2 Assist with person
Toileting 3 Assist with device and Toileting
R person
E Transferring 4 Total dependence Transferring
S
T
Feeding Feeding
A
N Continence - Continence -
D SLEEP PATTERN: SLEEP PATTERN:

A Position: Position:
C Characteristics: Characteristics:
T
I
BODY FRAME:
V
I
T POSTURE:
Y
GAIT:

COORDINATION:

BALANCE:
Unsteady

MUSCLE (skill)
Strength: -
Right Arm 5Active motions against full
Left Arm resistance.
Right Leg 4 Active motion against
Left Leg some resistance.
3 Active motion against
Mass/Tone: gravity.
2 Passive ROM (gravity
Right Leg removed and assisted by
Left Leg - examiner)
1 Slight flicker of contraction.
0 No muscular contraction.

0No increase in muscle tone


1Slight increase in muscle
Right Arm tone, manifested by a catch
Left Arm - and release or by minimal
resistance at the end of the
range of motion when the
affected part(s) is moved in
flexion or extension
1+ Slight increase in muscle
tone, manifested by a catch,
followed by minimal resistance
throughout the remainder (less
than half) of the ROM
Tremors: 2More marked increase in
muscle tone through most of
No tremors the ROM, but affected part(s)
easily moved
Motor Function: 3 Considerable increase in
muscle tone, passive
Fine: movement difficult
Gross: 4 Affected part(s) rigid in
Range of motion (discuss) flexion or extension

She participated well in some of


the ROM Exercises instructed
by the Student Nurse.

Cervical spine
Flexion of the cervical spine
is 45 degrees. The
extension of cervical spine
is 45 degrees.

Thoracic and lumbar


the client cannot bend
backward or inward

Shoulders and arms


Can abduct both shoulders
and arms

Elbows
Increased ROM against
resistance on both elbow
Wrists
The client is able to bend
S the both wrist down and
A
back
F
E Hands and fingers
T The client was able to move
Y the both hand
Hips
A The client was able to move
N the both for hip assessment
D
Knees
E The client can extend or flex
N both knees
V Ankles and feet
I
R
Both ankles can abduct,
O adduct and dorsiflex.
N She can turn foot outward
M and inward
E
N Use of Device:
T None

ALLERGIES:
Medication
Food
Environment
EYES:
Vision
Accommodation PERRLA
Conjunctivae
Sclera Clear
Cornea White
Glasses No eye glasses
HEARING/HEARING AID:
No hearing aid Able to answer whispered
No hearing Impairment questions.
The client doesnt use
hearing aid.
MUCOUS MEMBRANE:
Lips
Oral Activity
AIRWAY CLEARANCE:
Nose: No secretions; Clear The client is able to
Mouth: No lesions and sniff through each
secretions noted; Clear nostril without difficulty.
No blockages or
O obstructions noted.
X RESPIRATION:
Y Rhythm: -Even or Uneven Rhythm:
G Effort:
E Effort: -Ease, quiet or with great effort
N Depth:
A Expansion:
T Depth: -Deep or shallow
I Cough:
O Expansion: -Symmetric or asymmetric
N
Auscultation:
Cough: -Productive or Non-productive
or absent

Auscultation: -Air exchange throughout


lungs
-Presence of diminished, Oxygen therapy:
lowered, or distant sounds
-Absence of sounds

Oxygen therapy:

Lung sounds:
No crackles and Rales upon
auscultation
Normal breath sounds.
N
U SKIN INTEGRITY: (insert picture)
T Color
R Texture
I
T Edema
I Temperature
O
N Turgor
NAILS:
Color:
Capillary Refill:
PERIPHERAL PULSE:
Location: Pulse scale: Location:
Pulse scale: 0-Absent Pulse scale:
Color: 1+ -Diminished, barely Color:
Skin: palpable, easy to obliterate Skin:
Edema: 2+ -Easily palpable Edema:
3+ -Full pulse, increased
4+ -Strong, bounding, cannot
be obliterate

1-Slight pitting, no visible


distortion, disappears rapidly
2-Somewhat deeper pit than
+1, no readily detectable
distortion, disappears in 10-15
sec
3-Pit noticeably deep, may last
more than a minute; the
dependent extremity looks
fuller and swollen
4-Pit very deep, last 2-5min;
dependent extremity is grossly
distorted.

IVF:
Site: Site:
Solution: Solution:
Regulation: Regulation:
Incorporation: Incorporation:

HOSPITAL DIET/RESTRICTIONS:
Therapeutic Diet: (NPO) Therapeutic Diet:
Fluid Intake: Fluid Intake:
Gag Reflex: Intact Gag Reflex: >underweight, over, or normal
Height: Height: After pregnancy; what is her bmi?
Weight: Weight:
BMI: Underweight = <18.5 BMI:
Normal weight = 18.524.9
Overweight = 2529.9
Obesity = BMI of 30 or
greater