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Nursing Assessment
NUR 101
Student Name:
_________________________________________
Patient Initials: __________ Age: ______ Gender ______
Key
+ pt has this
Ø pt does not have this
* unable to assess and requires explanation
DO NOT LEAVE BLANK SPACES
SECTION 1: GENERAL INFORMATION
Admission date __________ Assessment date __________
Source of information: _______________________________Reliability (1-4 with 4 being very reliable)____________
Advance Directives:
No
Yes – if yes:
DNR
health care proxy
living will
power of attorney
Copy on chart
Yes
No: if no: comment __________________________________________
Arm bands:
ID
Mastectomy
Allergy
Latex
Other Precautions_________________________________
Oriented: call bell, bathroom, activity level, meal times, visiting, no smoking policy
Yes
No
If no: comment ________________________________________________________________________________
Allergies: ______________________________________________________________________________________
SECTION 2: PATIENT HISTORY
Medications (include Rx, OTC drugs, sleep aids, herbs & alternative medicines)
Name
Dose & Frequency
Reason for taking
Other medications taken at home:
Chief Complaint/Reason for Admission:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Past Medical History: (indicate date of onset of all health stressors)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Past Surgical History (year/procedure):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RESPIRATION
Subjective (Reports)
Dyspnea/related to:
Cough/sputum:
History of Bronchitis: _____
Asthma:
Emphysema:
Tuberculosis:
Recurrent pneumonia:
History of smoking:
Use of Oxygen: _________________
Flu Vaccine ______________ Pneumonia Vaccine ________
Other: _____________________________________________
Nursing diagnosis:
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Objective (Exhibits)
Respiratory: Rate: ___________ Depth: _____________
Pulse Oximetry: _________________________________
Symmetry: _____________________________________
Use of accessory muscles: __________________________
Nasal flaring: ___________________________________
Breath sounds: _____________Cyanosis: _____________
Clubbing of fingers: _______________________________
Cough: nonproductive: ___________________________
Cough: productive: _______________________________
Sputum characteristics: ____________________________
Restlessness: ____________________________________
CIRCULATION
Subjective (Reports)
Objective (Exhibits)
History of: Hypertension: _____ Dysrhythmias: _______
PVD: _____ CAD: ______MI: _______Pacemaker ______
Ankle/leg edema: __________
Phlebitis: ______ Slow healing: _________________
Bleeding disorder: _____________________
Palpitations: ____________ Syncope: ______________
Extremities: Numbness: ________ Tingling: __________
Fatigue: ________________________________________
Blood Transfusion: ___________Cardiac Surgery_________
Stroke:______________________
Other: _______________________________
Nursing Diagnosis:_____________________________
BP: _____________ Apical: ______
Pulse Scale (0-3)
Radial: _______ Femoral: _________
Post.tibial: _______ Dorsalis pedis: _________
Heart sounds: Rate: _______ Rhythm: _____________
Quality: ____________
Extremities: Temperature: ________ Color: __________
Capillary refill: _____ ___________________
Varicosities: _______ Edema: __________
Color: General: __________________________________
Mucous membranes: _________ Lips: ______________
Nailbeds: _________ Conjunctiva: _________________
Sclera: _______________ Diaphoresis_______________
NEUROSENSORY
Subjective (Reports)
Objective (Exhibits)
Fainting spells/dizziness: ___________________________
Headaches: Location: __________ Frequency: ________
Tingling/numbness/weakness (location): _______________
Stroke/brain injury (residual effects): _________________
Seizures: ___________
Eyes: Vision loss: __________ Last exam: ___________
Glaucoma: _______________ Cataract: ____________
Ears: Hearing loss: _________ Last exam: ___________
Epistaxis: ____________
Speech:____________________
Other: _________________________
Nursing diagnosis: ________________________________
Mental status (Note duration of change):
Oriented/disoriented: Person: _____________________
Place: _______ Time: _______ Situation: __________
Alert: _____ Drowsy: ______ Lethargic: ___________
Stuporous: ______________ Comatose: ____________
Cooperative: _____________ Combative: ____________
Delusions: ____________ Hallucinations: ___________
Affect (describe) _______________Speech:____________
Memory: Recent __________ Remote: ______________
Glasses: _______ Contacts: _____ Hearing aids: ______
Pupil: Shape: _______ Size/reaction: R/L: ____________
Handgrasp/release: R/L: __________Paralysis: _________
PAIN/DISCOMFORT
Subjective (Reports)
Location: _______________
Intensity (0-10 with 10 being most severe): __________
Frequency: ____________ Quality: _________________
Duration: _____________ Radiation: _______________
Precipitating/aggravating factors: ____________________
How relieved: ___________________________________
Associated symptoms: _____________________________
Effect on activities: ___________________
Other: ____________________________
Nursing diagnosis: _____________________________
Objective (Exhibits)
Facial grimacing: _________________________________
Guarding affected area: ____________________________
Emotional response: ______________________________
Narrowed focus: __________________________________
Change in Blood Pressure: __________ Pulse: ________
SAFETY AND INTEGUMENTARY
Subjective (Reports)
Objective (Exhibits)
Temperature: _______ Diaphoresis: ________________
Skin integrity: Scars: __________ Rashes: ___________
Tattoos: _____ Piercings: _____ Lacerations:_________
Ulcerations: _______Ecchymosis: _____ Blisters: ______
Burns: ______Drainage: _______ Dressing type: ______
Wound size: ______ Tubes/appliances:_____
Mark location of the above on diagram:
Allergies/sensitivity: ________ Reaction: _____________
History of falls and injuries: _______________________
Fractures/dislocations: ____________________________
Use of assistive devices (specify):_____________________
Arthritis/unstable joints: ___________________________
Back problems: __________________________________
Changes in moles: ________ Delayed healing: _______
Other: ____________________________
Nursing diagnosis: _______________________________
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FOOD/FLUID
Subjective (Reports)
Objective (Exhibits)
Usual diet (type): _________________________________
Cultural/religious restrictions: _______________________
Number of meals daily: ____________________________
Vitamin/food supplement use: ______________________
Dentures: ____ Loss of appetite: __________________
Food preferences: _______ Food prohibitions: ________
Allergy/food intolerance: ___________________________
Mastication/swallowing problems: ___________________
Usual weight: __________ Changes in weight: _______
Satisfaction with body weight: ________________________
History of Diabetes:_____Type 1________Type 2__________
History of GERD: _________Diverticulitis/Ulcer ____________
History of Hepatitis: _________ Hypo/Hyperthyroid __________
Other: _________________________________
Current weight: ______ Height: ______
Body build: _____________ Skin turgor: _____________
Mucous membranes: Moist/dry: _____________________
Edema: General: _________ Dependent: ____________
Periorbital: ______________ Ascites: _______________
Scale (1-4):________________________________
Condition of teeth/gums: __________________________
Appearance of tongue: ___________________________
Dysphagia:___________________________
Serum glucose (Glucometer) ________________________
Nursing Diagnosis:______________________________
ELIMINATION
Subjective (Reports)
Objective (Exhibits)
Usual bowel pattern: ______________________________
Laxative use: ____________________________________
Last BM: __________ Character of Stool:_____________
History of bleeding: __________ Hemorrhoids: ________
Usual voiding pattern: _____________________________
Frequency: ____________ Retention: ______________
Pain/burning/difficulty voiding: ______________________
History of kidney/bladder disease: ___________________
Diuretic use: _____________________________________
Incontinence/when: ___________ Urgency: __________
History of STD:_______________ BPH: _______________
History of UTI:________ESRD:__________________
Other: __________________________________
Abdomen: Tender: _________ Soft/firm: ____________
Bowel sounds: Location/type: _____________________
Hemorrhoids: ____________ Stool guaiac: _________
Tubes:
Foley catheter: ______________________
Ostomies: ______________________________________
Character of stool: ________________________________
Character of urine: ________________________________
Incontinence: ____________________________________
Nursing Diagnosis: ________________________________
EGO INTEGRITY
Subjective (Reports)
Stress factors: ___________________________________
Ways of handling stress: __________________________
Relationship status: _______________________________
Recent losses: __________________________________
Cultural factors/ethnic ties: _________________________
Religion: _______________ Practicing: ____________
Feeling of: Helplessness: _________________________
History of drug abuse _________________________
History of alcohol abuse _______________________
Other: ____________________________________
Objective (Exhibits)
Emotional status:
Calm: _________ Anxious: _______ Angry: ________
Withdrawn/Fearful: ________ Irritable: _____________
Apprehensive: ____________ Euphoric: ____________
Other: __________________
Observed physiological response(s): __________________
Nursing Diagnosis: _______________________________
ACTIVITY
Subjective (Reports)
Objective (Exhibits)
Occupation: ___________ Usual activities: ___________
Leisure time activities/hobbies: ______________________
Limitations imposed by condition: ____________________
Sleep: Hours: _______ Naps: _______ Aids: ________
Insomnia: ______________ Sleep apnea _______________
Feelings of boredom/dissatisfaction: __________________
Other: _____________________________________
Observed response to activity:
Palpitations: _________Shortness of Breath: ____________
Muscle mass/tone: ___________ Posture: __________
ROM: _______ Strength: _______ Tremors: ________
Deformity: _____________________________________
Nursing diagnosis: ________________________________
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HYGIENE
Subjective (Reports)
Objective (Exhibits)
Activities of daily living: Independent (I) Dependent (D):
Mobility: ____________ Feeding: __________________
Hygiene: ____________ Oral Hygiene: _____________
Dressing/grooming: __________ Toileting: __________
Preferred time of personal care/bath: _________________
Equipment (shower chair/commode): _______________
Assistance provided by: ____________________________
Other: ______________________________________
General appearance: ______________________________
Manner of dress: _________________________________
Personal habits: __________________________________
Body odor: _____________________________________
Condition of scalp: _______________________________
Nursing diagnosis: ________________________________
SOCIAL INTERACTIONS
Subjective (Reports)
Objective (Exhibits)
Marital status: _______ Years in relationship: _________
Living with: ________ Concerns/stresses: ___________
Extended family: _________________________________
Other support person(s): __________________________
Role within family structure: ______________________
Ethnic affiliation: ________________________________
Suicide Attempt________________Ideation____________
Problems related to illness/condition: _________________
Other: _______________________________________
Verbal/nonverbal communication with family/significant other:
________________________________________________
Family interaction (behavioral pattern)
________________________________________________
Nursing diagnosis: ________________________________
TEACHING/LEARNING
Subjective (Reports)
Dominant language (specify): _______________________
Second language: ____________Interpreter needed: Y/N
Literate: ________ Education level: ________________
Learning disabilities: (specify): ____________________
Cognitive limitations: ____________________________
Health and illness beliefs/practices (e.g., complementary
therapies) customs: ______________________________
Which family member makes healthcare decisions/is
spokesperson: __________________________________
Self Breast Exam:____Testicular Exam:_____Last Mamo____
Pap Smear:___________ Prostate Exam:_________
Other: _____________________________________
Objective (Exhibits)
Readiness for Learning:__________________________
Learns Best By:_______Visual ___________Auditory
____________Kinestitic
Barriers to Learning:____Cognitive_____Visual
_____Hearing _____Memory ____Language
Nursing diagnosis: ________________________________
DISCHARGE PLAN CONSIDERATIONS
Date information obtained: _________________________
Anticipated date of discharge: _______________________
Resources available: Persons: ______________________
Financial: ___________ Community: ________________
Support groups: _________________________________
Areas that may require alteration/assistance:
Food preparation: ________ Shopping: _____________
Transportation: __________ Ambulation: ___________
Medication/IV therapy: ___________________________
Treatments: ____________ Wound care: ___________
Supplies: ___________ Self-care (specify): __________
Homemaker/maintenance (specify): _________________
Physical layout of home (specify): __________________
Other: ____________________________________________
Anticipated changes in living situation after discharge:
_______________________________________________
Living facility other than home (specify):
_______________________________________________
Referrals (date, source, services):
Social Services: _________________________________
Rehabilitation services: ___________________________
Dietary: ___________ Home care: _________________
Resp/O2: ___________ Equipment: ________________
Supplies: ______________________________________
Other: ________________________________________
Nursing diagnosis: ________________________________
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