Patient Assessment Tool

Client Name: Room #: Doctor: Report Data:

Sex: DOB/Age: Height: Weight: Ethnicity: Education Level: Occupation: Religion: Oriented: to person⃞ place⃞ time⃞ Activity: gait_____ mobile⃞ bed bound⃞ 1- or 2-assist⃞ walker⃞ cane⃞ wheelchair⃞ splint⃞ crutches⃞ cast⃞ lift________ contractured⃞ amputation⃞ total care⃞ ADLs: ____________ Body build: grossly obese⃞ overweight⃞ average⃞ slim⃞ Mental Status: lethargic⃞ calm⃞ anxious⃞ irritable⃞ fearful⃞ depressed⃞ other⃞

Precautions/Isolation: Allergies: Diet: Admitting date & Dx: Additional Dx: Family Hx:

T: I&O:

Other Info: P:

R:

B/P:

SaO2:

Pain:

Head: symmetrical⃞ asymmetrical⃞ masses⃞ non-tender ⃞ Hair: evenly distributed⃞ shiny⃞ dry scalp⃞ balding⃞ lesions⃞ dandruff⃞ lice⃞ Eyes: PERRLA⃞ symmetrical⃞ drainage⃞ edema⃞ drooping lid⃞ glasses⃞ contacts⃞ Ears: symmetrical⃞ drainage⃞ lesions⃞ tenderness⃞ HOH⃞ hearing aid⃞ Nose: symmetrical⃞ drainage⃞ sense of smell⃞ tenderness⃞ Mouth: lips dry⃞ lips moist⃞ mucous membranes moist⃞ dry⃞ lesions/sores⃞ teeth missing⃞ gingivitis⃞ dentures upper ⃞dentures lower⃞ teeth grinding⃞ Pulse: regular⃞ irregular⃞ weak⃞ strong⃞ bounding⃞ pulses equal⃞ Grips: weak⃞ strong⃞ equal⃞ ROM: (Head, neck, arms, hands, hips, legs, & feet) Respirations: asthma⃞ inhaler⃞ Depth: normal⃞ deep⃞ shallow⃞ Effort: labored⃞ unlabored⃞ Sounds: clear⃞ congested⃞ crackles⃞ wheezing⃞ Cough: productive⃞ non-productive⃞ frequent⃞ occasional⃞ describe sputum: Heart sounds: strong⃞ weak⃞ normal (S1 & S2) ⃞ abnormal (S3 or S4)⃞ Bowel sounds: all 4 quad?⃞ normal⃞ sluggish⃞ hyperactive⃞ high pitch⃞ low pitch⃞ last elimination________ Abdomen: pain⃞ non-tender⃞ distended⃞ non-distended⃞ soft⃞ firm⃞ Bladder: distended⃞ non-distended⃞ Joints: arthritis⃞ spinal curvature⃞ pain⃞ BM: continent⃞ incontinent⃞ constipated⃞ diarrhea⃞ soft⃞ formed hard ⃞ loose⃞ bloody⃞ brown⃞ Urine: continent⃞ incontinent⃞ clear⃞ cloudy⃞ yellow⃞ amber⃞ bloody⃞ sediment⃞ UTI⃞ Voids: with⃞ without difficulty⃞ Skin: Characteristics: abnormal moles⃞ rashes⃞ bruising⃞ ulcers⃞ lacerations⃞ diaphoretic⃞ warm& dry⃞ cool & clammy ⃞ Integrity: good⃞ scars⃞ tears⃞ stitches⃞ risk for impaired⃞ Color: pink⃞ ruddy⃞ pale⃞ flush⃞ Edema: yes⃞ no⃞ non-pitting⃞ pitting⃞ grading (+1- +4) __ TED hose⃞ Turgor: elastic⃞ tenting⃞ Capillary Refill: brisk⃞ sluggish⃞ < 3 sec⃞ how long if > 3 sec______ Pain: Location_______ Intensity (0-10) ____ Quality_____ Duration______ Pain Reliever(s)_____________ Wound: Location__________ Condition: pink⃞ red⃞ necrotic⃞ Drainage: sanguinous⃞ serosanguinous⃞ serous⃞ purulent⃞ Drain condition_______ Drain type________ Amount: ____mL Dimensions: _____________ Stoma: type__________ location____________ skin integrity________ O2: Rate_________ Nasal Cannula⃞ Mask⃞ Reason__________ IV: location___________ condition_______ fluid__________ rate________ G-Tube/NG Tube: intake_____ output______ infusion rate_____ formula______ skin integrity________ Catheter: condition______ size____ amount_____ color_______ reason_______ cloudy⃞ clear⃞ milky⃞ sediment⃞

Trade Name

Date Performed:

Generic Name

Lab:

Class.

Dose

Route

Freq.

Result:

Nursing Dx Problem #1:

Nursing Dx Problem #2:

Nursing Dx Problem #3:

Nursing Dx Problem #4:

Reason