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COLLEGE OF NURSING
ASSESSMENT TOOLS
Has received blood in the past? Yes _____ No ______ if yes, list dates_________________
Allergies:
Food: ______________________________________________________________________________
Medications: _________________________________________________________________________
Admitting Diagnosis:
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II. NURSING ASSESSMENT
A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.
Objective Subjective
General Appearance: □ Alert/responsive Usual Diet: ___________________________________
□ Apathetic □ Cachexia □ Abdominal Distention No. of meals per day: ___________ (3x a day)
No. of fluid drink each day: _______(8-12 glasses/day)
□ Mass □ Tenderness/pain
Skin: □Dry □Warm □Cold □Moist □Edema
□ Alcohol and Beverages ________________________
Turgor: ____________________________________
Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort
Objective Subjective
Breath Sounds: □ Diminished/Absent □ Stridor Previous/Recent Illnesses:
□ Rales/Crackles □ Rhonchi/Wheezing □ Bronchitis □ Emphysema □ Asthma
□ Normal (Vesicular, Bronchovesicular, Bronchial) □ Brochiectasis □ Pneumonia □ Hydrothorax
□ None (atelectasis) □ Pneumothorax □ Hemothorax □ CHF
□ Chest Trauma □ Lung Cancer
Resonance: □ Hyper □ Hypo Comment: ____________________________________
_____________________________________________
Respiration/Oxygenation: _____________________________________________
□ Normal(Relax, Effortless and Quiet) _____________________________________________
□ Labored/Use accessory Muscle] □ Dyspnea
□ Tachypnea □ Bradypnea □ Cyanosis Breathing Treatments/Medication: ______________
□ Pallor □ Cheyne-stoke □ Biot’s _____________________________________________
□ Hyperventilation □ Hypoventilation _____________________________________________
□ Nasal Flaring □ Pursed lip □ Barrel Chest _____________________________________________
□ Pleuritic Pain
Smoking:
□ O2 Inhalation _____liters/min
Rate: ________________________ □ Yes For how long: __________
Tube/Drainage: □ CTT □ Oral Airway □ No
Comment:____________________________________
□ Endotracheal Tube □ Ventilator
_____________________________________________
_____________________________________________
Cough: □ Productive □ Non-productive _____________________________________________
Sputum: □ Mucoid □ Bloody (hemoptysis) _____________________________________________
□ Rusty □ Frothy □ Thick Tenacious
Color: ____________________________
Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.
Objective Subjective
Temperature: _______________ Celsius Previous/Recent Illness:
Blood Pressure: Right_______ Left ___________ □ CVA □ CHF □ MI □ Thrombophlebitis
□ Family History of HPN □ Renal Failure
Pulses:
Carotid Pulse: □ Thready □ Weak □ Strong/bounding
□ Bleeding Disorder __________________________
□ Absent Rate: Right______Left______ Comment: ____________________________________
_____________________________________________
Apical: □ Regular □ Irregular Rate: ____ _____________________________________________
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Radial Pulse: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right______ Left _______
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Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak Do you experience any of the following:
□ Strong □ Absent Rate: Right_____ Left _____
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak
□ Chest pain □ Arm pain □ Leg pain
□ Strong □ Absent Rate: Right_____ Left _____ □ Joint and Back □ Dyspnea □ Orthopnea
□ Numbness and Tingling
Heart Sounds:____________ □ Light headedness □ Fatigue and weakness
Heart Rhythm: □ Tachycardia □ Bradycardia □ Palpitations
□ Arrhythmia/ Dysrhythmia Comment: ___________________________________
_____________________________________________
Jugular Veins Distention: _____________________________________________
□ Positive □ Negative
Exercises:
Nail bed Color : □ Pink □ Blue □ Pale
Type: _______________________________________
Capillary Refill: ________ (Normal less than 2 sec) Frequency: __________________________________
Duration: ____________________________________
Edema: □ Pitting □ Non Pitting
Problem experience with usual activity and exercise:
Location: _____________________________
Comment: ____________________________________
_____________________________________________
Varicosities: □ Yes □ No
Location: __________________________________ Factors Affecting Activity Intolerance:
Comment: ____________________________________
Calf Tenderness (Homan’s Sign): _____________________________________________
Right □ Positive □ Negative
Left □ Positive □ Negative
Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective Subjective
Skin: □ Dry □ Intact □ Warm □ Cold □ moist Comment : ___________________________________
Turgor:_____________________________________ _____________________________________________
□ Pallor □ Cyanosis □ Jaundice □ Rashes _____________________________________________
□ Acanthosis Nigricans □ Albinism □ Erythema _____________________________________________
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□ Edema □ Petechia □ Itching □ Drainage _____________________________________________
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer Comment:____________________________________
Temperature: _________ _____________________________________________
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Hair: □ Alopecia □ Hirsutism □ Patchy hair loss
Distribution: ________________________________ Comment:____________________________________
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Nails: □ Dirty □ Pallor □ Cyanosis _____________________________________________
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□ Clubbing □ Paronychia □ Onycholysis
Capillary refill: __________ (Normal less than 2 sec)
Color: _________________
Remarks: _________________________________________________________________________________
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Nursing Diagnosis:
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E. ELIMINATION
Objective Subjective
Tubes/Drainage/Stoma: Previous/Recent Surgery/Illness:
□ Colostomy □ Ileostomy □ NGT _____________________________________________
□ Catheter □ Suprapubic Catheter
History of pain and discomfort: _________________
_____________________________________________
Abdomen: □ Soft □ Firm
□ Distended □ Non-distended Personal Elimination Habits:____________________
_____________________________________________
Bowel Sounds: (5 – 20 sounds/min)
□ Normoactive □ Hypoactive Elimination Problem:
□ Hyperactive(Borborygmi) □ Absent □ Loose bowel movement _________
□ Constipation □ Impaction □ Fecal Incontinence
Measurement:
□ Neurologic Impairment □ Dysuria □ Urgency
Intake ____________ Output:_______________
□ Polyuria □ Oliguria □ Nocturia □ Dribbling
Edema: □ Yes □ No □ Incontinence □ Hematuria □ Retention
Location: __________________________________ □ Discharge
□ Urinary Elimination changes _________________
□ Residual urine (> 100ml)
Present Urine Color: ________________________ Comment: ___________________________________
_____________________________________________
Note: Assess urine frequency, color, odor control,
comfort/gyn-bleeding, discharge. Medication taken: □ Analgesic Narcotic
□ Antibiotics □ Anticholinergic □ NSAID
Comment: __________________________________
___________________________________________ □ Aspirin □ H2 antagonist
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___________________________________________ Fluid intake per day: __________ liters/day
___________________________________________
___________________________________________ Physical Activity: _____________________________
___________________________________________ Comment: ___________________________________
_____________________________________________
Excessive Perspiration and Odor Problem:
□ Yes □ No
Consistency:
Stools: ______________________________________
Remarks: _________________________________________________________________________________
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F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.
Objective Subjective
Mobility: □ Ambulatory □ Non Ambulatory Do you experience any of the following:
□ Bedridden □ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Appliance __________________________ □ Joint pain
Gait and Posture: □ Lordosis □ Kyphosis Comment ____________________________________
_____________________________________________
□ Scoliosis □ Shuffling □ Poliomyelitis
_____________________________________________
□ Amputated Limb ______________________
Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
□ Contractures/Deformities □ Crepitus
□ Tingling/Numbness (Carpal Tunnel Syndrome)
□ Ankylosis □ Foot Drop □ Pressure Ulcers Comment: ___________________________________
_____________________________________________
Calf Tenderness (Homan’s Sign): _____________________________________________
_____________________________________________
Right □ Positive □ Negative
Left □ Positive □ Negative
Remarks: _________________________________________________________________________________
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G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC
Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,
Objective Subjective
LOC: □ Alert □ Lethargic □ Comatose Check the Following Risk Factors:
□ Unresponsive □ Obtunded □ Stupor □ Older Adulthood □ Male □ Hx Stroke or TIA
□ Hypertension □ Smoking □ Hx CVD
GCS Score: _________ □ Sleep Apnea □ High level of Cholesterol
□ Drug Abused □ DM □ Oral Contraceptives
Cushing Triad (Respiratory changes, Increase BP,
□ Menopausal □ Over weight
Decreasing level of Consciousness)
Comment: ____________________________________
□ Positive □ Negative
Do you experience any of the following:
Sensation: □ Positive □ Negative □ Blurring □ Diplopia □ Photophobia
□ pain □ Inflammation □ Cataract
Pupillary Size: □ PERRLMAE □ Anisocoric
□ Glaucoma □ Headache □ Unusual Discharges
Comment: ____________________________________
Orientation: □ Person □ Place □Time/Date _____________________________________________
□ Pain
Sensory Function: □ Positive □ Negative
Location: __________________________________
Reflexes:
Patellar □ Positive □ Negative
Biceps □ Positive □ Negative
Triceps □ Positive □ Negative
Achilles □ Positive □ Negative
Remarks: _________________________________________________________________________________
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Activity Score
EYE OPENING
MOTOR RESPONSE
VERBAL RESPONSE
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III. LABORATORY AND DIAGNOSTIC EXAMINATION
Date LABORATORY AND Result Significance
Ordered DIAGNOSTIC
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IV. NURSING CARE PLAN
DATA NURSING DX OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
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V. DRUG STUDY
Name of Drug Dose/
Mechanism of
Generic Classification Frequency/ Indication Contraindication Side effects Nursing Precaution
action
(brand) Route
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VI. SOAPIE (First day)
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VI. SOAPIE (Second day)
Exercise:
Treatment:
Diet:
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VII. PATHOPHYSIOLOGY
Name of Patient: __________________________________ Age: ______________ Sex _________________
Diagnosis: ________________________________________________________________________________
Definition:
Reference:
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