CAPITOL UNIVERSITYCollege of Nursing
NURSING ASSESSMENT FORM
A. Demographic Data
 Name of Client _________________________________________ Unit/Ward __________ Bed ________ Age _________ Sex _________ Civil Status _____________ Religion ___________________________ Date of Admission _______________________ Medical Diagnosis ____________________________________________ Examiner ________________________________ Information given by ________________________________________ 
B. Vital Signs
Temp ___________ 
oral
axilla
rectal BP ___________ 
lying
sitting
standingPulse ___________/ min.
regular 
irregular Resp ___________/ min.
regular 
irregular Height ___________ cm. Weight ____________ kg.
C. Health Patterns Assessment:
Complete information, including patient’s words. Indicate N/A if non-applicable. Circle,code, or check all findings as appropriate.
1.Health Perception and Health Management Pattern
Reason for hospitalization/chief complaint ________________________________________________________________  ___________________________________________________________________________________________________  ___________________________________________________________________________________________________ History of present illness ______________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________ Previous hospitalizations/surgeries_________________________________________________________________________  _____________________________________________________________________________________________________  ____________________________________________________________________________________________________ What other health problems have you had? __________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Things done to manage health ____________________________________________________________________________  ____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Statement of patient’s general appearance ___________________________________________________________________  _____________________________________________________________________________________________________  _____________________________________________________________________________________________________ Tobacco use:
Yes
No Used to smoke ______________ packs/day for __________ yearsAlcohol use:
Yes
No Amount: _______________ Frequency: _________________ Duration: _____________ Coffee/Cola/Tea Intake:
Yes
No Amount: ___________ Frequency: ____________ Duration: _____________ Recreational/Illicit Drug use:
Yes Specify: _____________________ 
NoAllergies:
Yes (list with reaction experienced)
NoFood: __________________________________________ Medications:_____________________________________ Others: ________________________________________________________________________________________ 
Medications:
 NAMEDOSESCHEDULEINDICATIONSHave you been taking your medication(s) as prescribed? ________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________ 
 
2.Nutrition and Metabolic Pattern
Special diet? _____________________________________________ Supplements: ________________________________ Pattern of daily food/fluid intake (describe amount/quantity) ____________________________________________________  _____________________________________________________________________________________________________ Appetite: ________________________________________________ Wt. loss/gain? ________________________________  Nausea/Vomiting: _________________________________________ 
Hematemesis
Coffee-ground vomitusFood/eating discomforts________________________________ GI pain ___________________________________________  Nutritional state:
well-nourished
poorly nourished
obesity
cachexia
 Mouth:
Lips:
pinkish
pallor 
cyanosis
dryness/cracks
lesions: ________________________________ Mucosa:
pinkish
pallor 
cyanosisTongue:
midline
R/L deviation
atrophy
fasciculationTeeth:
complete
missing teeth
caries
dentures: ________________ Gums:
pinkish
pallor 
bleeding
tenderness 
 Pharynx:
Uvula:
midline
R/L deviation Mucosa:
pinkish
pallor 
reddishTonsils:
not inflamed
R/L inflamed
R/L with exudatePosterior Pharynx:
inflammation/congestion
 Neck:
Trachea:
midline
R/L deviation Cervical lymph nodes:
lymphadenopathy
tendernessThyroids:
non-palpable
enlarged Others:
neck enlargement
normal ROM
neck rigidity
 Skin:
General Color:
pinkish
pallor 
jaundice
dusky
cyanotic
flushed
mottledTexture:
smooth
rough
others: __________________________ Turgor:
supple
firm
dehydrated
others: ___________________________ Temperature:
warm
cool
others: ______________ Moisture:
dry
moist/clammy
oilyOthers:
petechiae
ecchymosis
hematoma
lesions/rashes: ____________________________________  
edema: ____ pitting ____ non-pitting ____ pedal: R/L ______ bipedal Grading: ____________ Wounds/drains/dressings: _________________________________________________________________________________ Intravenous fluids _______________________________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________ 
3. Elimination Pattern
Usual bowel pattern (describe character of stool, frequency, discomforts) ___________________________________________  ______________________________________________________________________________________________________  _________________________________________________________________ Date of last BM: ______________________  
Melena
HematocheziaAny problems with hemorrhoids/incontinence? _______________________________________________________________ Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies” anti-diarrheals): _______________  _____________________________________________________________________________________________________ 
 Abdomen:
General :
superficial veins
straie
scars/lesions: ____________________ Configuration:
symmetrical
asymmetrical
flat
globular 
protuberant
scaphoidBowel Sounds:
normoactive
hyperactive
hypoactive
absentPercussion:
tympanitic
hypertympanitic
dullness at _________________________________  
fluid wave
shifting dullnessPalpation:
muscle guarding
direct tenderness
rebound tenderness
bladder distention 
organomegaly: ___ liver ___ spleen
masses at _____________________________________ Usual urinary pattern (describe frequency, character, amount, problem in control, etc.) ________________________________  ______________________________________________________________________________________________________  
dysuria
hematuria
nocturia
retention
flank pain
polyuria
oliguria
anuriaExcess perspiration/nocturnal sweats: _______________________________________________________________________ OTHER PERTINENT DATA: _____________________________________________________________________________  ______________________________________________________________________________________________________ 
4.Activity – Exercise Pattern
Exercise Pattern? (Type, Regularity) _______________________________________________________________________ Leisure Activities? _____________________________________________________________________________________ 
Cardiovascular Status:
chest pain/radiation: _______________________ 
palpitations
dyspnea on exertion 
orthopnea
paroxysmal nocturnal dyspnea
jugular vein distentionPrecordial area:
flat
bulging
tenderness
heave
thrillPoint of Maximal Impulse (PMI) _____________________ Apical rate & rhythm _____________________________ Heart Sounds:
distinct
regular 
faint
irregular S1 < > S2 at the base S1 < > at the apexOthers:
S3
S4
Murmur best heard at ________________ 
Pericardial rub
 
Peripheral pulses:
symmetrical
regular 
absent
faint/weak 
strong
boundingCapillary refill __________________________ 
clubbingPresence of Pacemaker/A-V Shunt/Hemodynamic monitoring ______________________________________________ 
 Respiratory Status:
Breathing Pattern:
regular 
irregular 
eupnea
hyperpnea
tachypnea
bradypnea 
dyspnea: rest / exertion
use of accessory muscles
ICS retractions/bulging
pain on respirationShape of Chest: Anterior-Posterior-Lateral Ratio AP_____: L_____ 
barrel chest
funnel
pigeonLung Expansion:
symmetrical
R / L decreased/lagVocal/Tactile Fremitus:
symmetrical
decreased / increased at _________________ Percussion:
resonant
dullness at ___________________ 
hyperresonant at ___________________ Breath Sounds:
vesicular 
bronchovesicular at _________________ 
bronchial at __________________  
rales/crackles at______________ 
wheezes at ___________________ 
rhonchi
pleural friction rubCough:
productive
non-productive Sputum: color _________ amount________ consistency __________ O2 supplement/ventilatory assistance_______________________________________________________________________ Resp. tubes (e.g. ET, trach, chest tube – describe secretions/drainage)_____________________________________________  ______________________________________________________________________________________________________  ______________________________________________________________________________________________________ ____________________________________________________________________________________________________ 
 Activities of Daily Living/ Mobility Status:
Use the Activity Level Code below to assess ADL & mobility statusADL Status Mobility Status0 total independence Feeding ________ Meal Preparation_____ Bed mobility _____________ 1 assist with device Bathing ________ Cleaning __________ Chair/toilet transfer________ 2 assist with person Dressing _______ Laundry __________ Ambulation ______________ 3 assist with device & person Grooming ______ Toileting __________ R.O.M. _________________ 4 – total dependenceReasons for ADL/Mobility limitation _______________________________________________________________________ Device used for assistance ________________________________________________________________________________ Exercise pattern (describe type, regularity) ___________________________________________________________________ 
 Back and Extremities:
Range of Motion:
full
symmetrical
decreased ROM (specify joint) _________________  
Joint tenderness/pain
joint swelling at ________________ 
varicose veins
deformities _____________ Muscle tone and Strength:
equally strong
symmetrical in size
R / L Upper / Lower Atrophy 
R / L Upper / Lower Paresis
R / L Upper / Lower ParalysisSpine:
midline
Kyphosis
Lordosis
ScoliosisGait:
coordinated
smooth
uncoordinated
shuffling
staggeringOTHER PERTINENT DATA ____________________________________________________________________________ ______________________________________________________________________________________________________ 
5. Cognitive – Perceptual Pattern
Level of Consciousness:
conscious
alert
confused
drowsy
stuporous
comatose
others_______ Orientation:
oriented
disoriented to : time / person / placeEmotional state:
calm
worried/anxious
restless
others: ______________________________________ Appropriate behavior/communication: ______________________________________________________________________  
dizziness
numbness
tingling sensation
 Head:
normocephalic
asymmetrical
enlarged
masses: _____________ 
others: ___________________ Facial Movements:
symmetrical
asymmetrical: lag at R / LFontanels:
closed
sunken
bulging
open: specify _____________________ Hair:
fine
coarse
dry
normal/even distribution
alopeciaScalp:
clean
dandruff 
lice
wounds/scars/lesions: specify_______________________________ 
 Eyes:
Lids:
symmetrical
R / L edema/swelling
R / L ptosis
lesions: __________________________ Periorbital region:
edema
sunken
discolorationConjunctiva:
pink 
pale
lesions
dischargesCornea & Lens:
opacity: R / L
lesions: __________ Sclera:
anicteric
subicteric
icteric
hemorrhagesPupils:
equal: size _____mm.
unequal: R= _____mm. L= _____mm.Reaction to Light: R -
brisk 
sluggish
fixed L -
brisk 
sluggish
fixedReaction to Accommodation:
uniform constriction / convergence
unequal constriction / convergenceVisual Acuity:
grossly normal
farsighted
nearsighted
wears eyeglasses/contact lensesPeripheral Vision:
intact/full
decreased/ limited: _________________________ 
 Ears:
External Pinnae:
normoset
symmetrical
tenderness
lesions
gross abnormalities ______________ External Canal:
discharge: ___foul smelling ___ serous ___ purulent ___mucoid
Cerumen: ____impactedTympanic Membrane:
intactGross Hearing:
normal
decreased
symmetrical
R / L deafness
 Nose:
alar flaring
shallow nasolabial fold Septum:
midline
deviated
perforated
 
Mucosa:
pinkish
pale
reddish Discharge:
serous
mucoid
purulent
bloodyPatency:
both patent
R / L obstruction
masses/lesions: describe __________________________________ Gross Smell:
normal/symmetrical
R / L olfactory deficiencySinuses:
tenderness: ____ maxillary ____ frontal
Cognition:
Primary language _________________________ Speech deficit _____________________________________ Educational attainment ______________________________________________________________________________ Any learning difficulties? ___________________________________________________________________________Any change in memory lately? ________________________________________________________________________ 
 Pain:
no problem
problem ( describe location, type, intensity, onset, duration of pain) ________________________ _________________________________________________________________________________________________ Methods of pain management: ________________________________________________________________________ 
6.Sleep – Rest Pattern
 Usual sleep/rest pattern: _______________________________________________________________________________ Adequate
yes
no Factors affecting sleep/rest: ______________________________________________________ Methods to promote sleep _____________________________________________________________________________ History of sleep disturbances ___________________________________________________________________________ 
7.Self-perception and Self-concept Pattern
How do you describe yourself ? ________________________________________________________________________ 
 
Are there any ways you feel differently about yourself since you’ve been ill/hospitalized? __________________________ __________________________________________________________________________________________________ Description of non-verbal behaviors: ____________________________________________________________________ _________________________________________________________________________________________________ 
8.Role – Relationship Pattern
Marital status _____________ Age and health of significant other _____________________________________________ Age and health of children ____________________________________________________________________________ __________________________________________________________________________________________________ Illnesses in the family ________________________________________________________________________________ Live
alone
family
others: ___________________________________________________________________ Family feelings regarding illness/hospitalization ___________________________________________________________ __________________________________________________________________________________________________ Who are the people that will help you most at this time? _____________________________________________________ Occupation: (any stresses/hazards?) _____________________________________________________________________ Financial support system: ______________________________________________________________________________ 
9.Sexuality Reproductive Pattern 
Any changes/problems with sexual relations? ________________________________________________________________ 
Female:
Menstrual pattern:___________________________________ Problems/changes: ____________________________ Date of LMP _________________________ Pregnancy history ____________________________________________ Use of birth control measure
yes
no
N/A Type: _____________________________________________ Any problem with use ? ______________________________ Monthly self-breast exam
yes
no 
 External Genitalia:
Labia:
symmetrical
asymmetrical
lesions __________________  
pinkish
discoloration
edemaUrethra:
pinkish
red/inflamed Vaginal Orifice Discharge:
purulent
bloody
foul-smellingOthers:
swelling
lumps/nodules 
 Breast:
equal
unequal Surface:
smooth
retraction
dimpling
edema
lesions 
tenderness
masses at _____________________ 
others: __________________________ 
Male:
Prostate problems? _____________________________ Monthly self-testicular exam
yes
no
 
Penis:
discharge ________________ 
nodules/growths/lesions
tendernessScrotum:
equal shape w/ L lower than R 
non-tender 
R/L enlargement
R/L undescended testes 
tenderness
nodules/growths/lesionsOthers:
hernia
hydrocoele
10. Coping – Stress Tolerance Pattern
Have you experienced any recent stressful situations in addition to your illness/hospitalization?
Yes
NoIf “Yes”, please describe briefly _______________________________________________________________________  __________________________________________________________________________________________________ Are there any ways we can be of assistance? ______________________________________________________________ How do you usually manage stresses? ___________________________________________________________________ What do you do for relaxation? _________________________________________________________________________ Support groups/counseling resources used: _______________________________________________________________ Were they helpful? __________________________________________________________________________________ 
11.Value – Belief Pattern
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