RLE FORM 001

Cebu Normal University

College of Nursing
Cebu City
NURSING ADMISSION AND ASSESSMENT

Name of Student: _____________________________________ Clinical Assignment: ______________________

Name of Clinical Instructor: ______________________________ Inclusive Dates: _________________________
A. General Admission Information
Name of Patient: ___________________________________________ Age: _________ Sex: ____________
Date: _______________ Time: __________ Mode: ________________ Allergies: ______________________
TPR: _________ BP: _________ HT: _________ WT: _________ Diet: ______________________________
Sleeping Habits: ___________________________________ CBC: Yes___ No___ Urinalysis: Yes___ No___
Property: Glasses ________
Prosthesis ______

Contact Lenses ________

Dentures ___________

Ring ___________

Watch Money _______

Other __________________________________________________________________________
Valuable to Business Office ________________________________________________________
Physical Appearance: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Behavior Exhibited: ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Content of Conversation: ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

_________________________
Physician In-charge
B. Admission Interview

1. Patient s perception of reason for admission: _____________________________________________

__________________________________________________________________________________
__________________________________________________________________________________

2. Patients symptoms as he/she sees them: ________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________

3. Problems in daily living created by symptoms (as patient views them)

__________________________________________________________________________________
__________________________________________________________________________________
4. Past Medical History (especially as it relates to P.I.)
Medical ________________________________________________________________________
Surgical ________________________________________________________________________
Allergies ________________________________________________________________________
Medication ______________________________________________________________________
Traumatic Injuries ________________________________________________________________
Orthopedic ______________________________________________________________________
Other (psychiatric, etc.) ____________________________________________________________
5. Habits
Smoking ______________________________ Alcohol ________________ Drugs _____________
Eating _________________________________________________________________________
Social Activity ____________________________________ Physical Exercise ________________
Rest/ Sleeping ___________________________________________________________________
_______________________________________________________________________________
e. Sexual _________________________________________________________________________
_______________________________________________________________________________
f.

Elimination ______________________________________________________________________

6. Social Economic History

a. Native Language: __________________
b. Education: ________________________
c. Occupation __________________________________________________________________
d. Financial Status (what is the impact of current hospitalization)
____________________________________________________________________________
____________________________________________________________________________
e. Civil Status:

Married______

f.

Lives alone ____________________________________________________

Living Situation:

Single ______

Divorced ______

Widow ______

Live with others (specify): _________________________________________

7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)
__________________________________________________________________________________
__________________________________________________________________________________

8. Primary Physicians Admitting Diagnosis (indicate P = Probable and C = Confirmed)

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

C. Nursing Review of Systems (circle the appropriate symptoms)

1. HEENT:

Headaches
Eye pain
Sinus pain
Sore throat

Hearing Loss
Eye infection
Facial pain
Nasal-tracheal pain

Visions
Diplopia
Blurring
Epistaxis
Bleeding gums
Dentures
Other___________________________

2. CARDIO-RESPIRATORY: Chest pain (site) _______________________________________________

Chest pain with exertion
Dyspnea on exertion
Nocturnal dyspnea
Edema
Hypertension
Palpation
Known murmur
Cough Sputum
Hemoptysis
Pleuritic pain
Diaphoresis
Last X-ray ___________________________________ EKG _________________________________
3. GASTRO-INTESTINAL
Thirst
Heartburn
Abdominal pain
Hemorrhoids Hernia

Nausea
Vomiting
Hematemesis
Difficulty Swallowing
Flatulence
Constipation
Jaundice
Diarrhea
Tarry Stool
Other: ________________________________________________________

4. GENITO-URINARY
Dysuria
Polyuria
Frequency
Urgency
Nocturia
Burning
Hematuria
Stones
a. Female Genital Tract Menstrual History:
Age
of
onset
_________________________________
Frequency __________________ Regulation _______________ Duration ____________________
Date of last period __________________________ Post menopausal bleeding ________________
Age __________ Symptoms ________________________________________________________
G ________________________ P _______________________ Ab _________________________
Male Genital Tract
Penile discharges
Lesions
Pain
Testicular swelling
Other __________________________________________________
Last Serology Test ________________________________________
5. MUSCULO-SKELETAL
Muscle pain
Extremity pain
Joint pain
Back pain
Joint swelling
Neck pain
Stiffness
Limited motion
Redness
Sprains
Deformity
Others ____________________________________________________________________________
X-rays ____________________________________________________________________________
6. NERVOUS
Convulsions
Syncope
Dizziness
Vertigo
Tremor
Speech difficulty
Limp paralysis
Paresthesia
Muscle atrophy
EEG ______________________________________________________________________________
Other _____________________________________________________________________________
7. ENDOCRINE
Goiter
Exopthalmus
Change in body contour

Tremor
Voice change
Infedility

Heat or Cold intolerance

Polydipsia
Other _________________________________

8. EMOTIONAL
Anxiety
Depression
Fear
Anger
Frustration
Other (specify) _________________________
Notes:_____________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

D. Nursing Observation
1. HEENT
a. Symmetry ______________________________________________________________________
b. Eyes and Pupils _________________________________________________________________
c. Ears ___________________________________________________________________________
d. Mouth and Throat ________________________________________________________________
e. Lymph nodes ____________________________________________________________________
2. RESPIRATORY
Depth and Rate __________________________________________________________________
Breath Sounds ___________________________________________________________________
Chest expansion _________________________________________________________________
3. CARDIO- VASCULAR
Blood Pressure (R)_________ (L)_________

Lying _____________ Standing ____________

Apical pulse rate and regularity ______________________________________________________

Pedal pulses rate per minute (R)________________________ (L)__________________________
Neck vein distension ______________________________________________________________
4. CHEST
Anterior chest ___________________________________________________________________
Posterior chest __________________________________________________________________
Breasts ________________________________________________________________________
Breasts and Axillae ____________________________________________________________
Anterior Thorax _______________________________________________________________
Posterior Thorax ______________________________________________________________
5. GASTRO-INTESTINAL
Bowel Sounds ___________________________________________________________________
Tenderness or rigidity _____________________________________________________________
6. URINARY
Bladder ________________________________________________________________________
7. SKELETAL
Joints __________________________________________________________________________
Range of Motions ________________________________________________________________
8. NEURO
a. Motor Function
1. Facial _______________________________________________________________________
2. Extremities ___________________________________________________________________
b. Sensory Function (equal or not equal)
c. Equilibrium
1. Balance _____________________________________________________________________
2. Finger to nose ________________________________________________________________
d. Reflexes (equal or not equal)
1. Knees _______________________________ Arms__________________________________
9. CRANIAL NERVE FUNCTION
a. Olfactory nerve: (sensory)
1. Sense of smell (coffee, vanilla. Etc.)
1.1 Anosmia __________________________________________________________________
1.2 Hyperosmia _______________________________________________________________
b. Optic nerve: (sensory)
1. Sense of vision (Snellens chart, newspaper)
1.1 Myiopia __________________________________________________________________
1.2 Hyperopia ________________________________________________________________

c. Oculomotor: (motor)
1. Extra-ocular movements/ Pupil reaction to light
1.1 Right eye _________________________

1.2 Left eye ____________________________

d. Trochlear: (motor)
1. Assess direction of gaze, upward and downward movement of eyeball
____________________________________________________________________________
e. Trigeminal: (motor)
Presence of corneal reflexes _____________________________________________________
1.1 Right eye _________________________

1.2 Left eye____________________________

2. Ability to clench teeth ___________________________________________________________

f.

Abducens: (motor)
1. Assess direction of gaze, lateral movements of the eyeballs
1.1 Right eye _________________________

1.2 Left eye ____________________________

g. Facial: (Sensory and motor)

1. Sense of taste: Using back of tongue
1.1 Salty _____________________________

1.2 Sweet _____________________________

2. Facial Expression
2.1 Smile _____________________________ 2.2 Puff out cheeks ______________________
2.3 Frown _____________________________ 2.4 Raise lower eyebrows _________________
h. Auditory nerve: (motor)
1. Sense of hearing
1.1 Right ear ___________________________ 1.2 Left ear ____________________________
i.

Glossopharyngeal: (Sensory and motor)

1. Sense of taste: Using back of tongue
1.1 Salty _____________________________

1.2 Sweet _____________________________

2. Ability to swallow (Use tongue blade to elicit gag reflex)

____________________________________________________________________________
j.

Vagus: (Sensory and motor)

1. Hoarseness of voice ___________________________________________________________
2. Sensation of pharynx ___________________________________________________________
Let patient say ah and observe movement of palate and pharynx

k. Spinal accessory: (motor)

Movement of:
1.1 Head ______________________________ 1.2 Shoulder ___________________________
l.

Hypoglossal: (motor)
1. Able to stick tongue to midline ____________________________________________________

10. EMOTIONAL
Communication __________________________________________________________________
Mood/ Effect ____________________________________________________________________
Behavior _______________________________________________________________________
E. Knowledge of Illness
Learning Limitations _________________________________________________________________

__________________________________________________________________________________2.
Learning Needs _____________________________________________________________________
__________________________________________________________________________________
F. Nursing Impressions
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
G. Nursing Problems (in priority)
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________
H. Discharge Planning
1. Probable Date ______________________________________________________________________
2. Destination ________________________________________________________________________
3. Transportation ______________________________________________________________________
4. Agencies and Equipment involved ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Diet ______________________________________________________________________________
6. Medications ________________________________________________________________________
__________________________________________________________________________________
7. Persons responsible for patient _________________________________________________________
8. Family conference ___________________________________________________________________
9. Anticipated problems _________________________________________________________________
10. Home visit _________________________________________________________________________

Rating Scale:
5

gives much more than what is expected

gives more than what is expected

gives what is expected

gives less than what is expected

gives much less than what is expected

_______________________________

________________________________

Signature of Student

Signature of Clinical Instructor