SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
ASSESSMENT TOOL
GENERAL INFORMATION
Name: ________________________________________________
Age: _______
Birthdate: _____________________
Address: ______________________________________________
Admission: Date:_____ Time: _________
From: Home: _________________________________________
Hospital: _______________________________________
Others: ________________________________________
HEALTH HISTORY
Reason for this visit (chief complaint):
_______________________________________________________
History of Present Illness:
________________________________________________________
______________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
____________________________________________________
History of Past Surgeries/ Hospitalizations:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
__________________________________________________
Diagnoses/ Impressions:
________________________________________________________
______________________________________________________

Bedtime rituals: _________________________________________

Relaxation techniques: ___________________________________
Sleeps on more than one pillow: ___________________________
Oxygen use (type): ______________________________________
When used: ____________________________________________
Medications/ herbals for/affecting sleep:
________________________________________________________
______________________________________________________
Objective (Exhibits)
Observed response to activity
Specific activity: ________________________________________
Before Activity
HR
RR
BP

Immediately after

After 5 minutes

Pulse oximetry: __________

Mental status (e.g. cognitive impairment/ withdrawn/ lethargic):
_______________________________________________________
Muscle mass/ tone (e.g. normal, flaccid, hypertonic, hypotonic,
spastic, rigid) ____________________________________________
Posture (e.g. normal, stooped, curved spine):
_______________________________________________________
Tremors: ______ Location: _________________________________
ROM: Describe: __________________
_______________________________
_______________________________
_______________________________

Strength:

Source of Information: ___________________________________

Date:___________________
ACTIVITY/ REST
Subjective (Reports)
Occupation:____________________________________________
Able to participate in usual activities/ hobbies:
________________________________________________________
______________________________________________________
Leisure time/ diversional activities:
________________________________________________________
______________________________________________________
Ambulatory:_____________
Gait (describe):__________________________________________
________________________________________________________
______________________________________________________
Activity level (sedentary to very active):
_______________________________________________________
Daily exercise (type): ____________________________________
Muscle mass/ tone/ strength (e.g normal, increased, decreased):
_______________________________________________________
_______________________________________________________
History of problems/ limitations imposed by condition (e.g. immobility,
cant transfer, weakness, breathlessness):
_______________________________________________________
________________________________________________________
______________________________________________________
Feelings (e.g. exhaustion, restlessness, cant concentrate
dissatisfaction): ________________________________________
_______________________________________________________
Sleep: Hours ___________________ Naps: _________________
Insomnia:________________ Type: _________________
Rested on awakening: ________
Excessive grogginess: _________

Uses Mobility Aid/s: _____________________________________

Nursing Diagnosis: ______________________________________
________________________________________________________
______________________________________________________
CIRCULATION
Subjective (Reports)
History of/ Treatment for (date):
High blood pressure: __________________________________
Head injury: __________________________________________
Stroke: ______________________________________________
Hemoptysis: __________________________________________
Heart Problem/surgery: _________________________________
Syncope: _____________________________________________
Spinal cord injury/ dysreflexia: ____________________________
Palpitations:___________________________________________
Bleeding tendencies episodes: ___________________________
Specify: ____________________________________________
Varicosities: __________________________________________
Heart problems/ Surgery: ________________________________
Thrombophlebitis: ______________________________________
Pain in legs with activity: _________________________________
Extremities: Numbness:_____ Location: ______________________
Tingling: ____ Location: __________________________________
Slow healing: sight (describe): ______________________________
_______________________________________________________
Medication/herbals: _______________________________________
Objective (Exhibits)
Color:Skin:_____________ Mucous membrane: ________________
Lips:_________________ Sclera: _________________________
Conjunctiva: ________________ Nailbeds: __________________
Skin moisture (e.g. dry, diaphoretic): _______________________

Page 17
Page

Blood pressure: lying:

R: _______ L ___________
Standing:
R: _______ L ___________
Pulse pressure: ____________
Auscultatory gap: ____________________________________
Pulses: Carotid: ___________
Describe: ___________________________________________
Temporal:__________
Describe:____________________________________________
Brachial: __________
Describe: ___________________________________________
Radial: ____________
Describe:____________________________________________
Ulnar: _____________
Describe: _____________________________________
Dorsalis pedis: ___________
If dorsalis pedis absent or abnormal,
post tibial_______________________________________
If post-tibial pulse absent or abnormal,
popliteal: ______________________________________
If popliteal pulse absent or abnormal,
femoral: ______________________________________
Cardiac (palpation): thrill ______ heaves: ______
Heart sounds (auscultation):
Rate:_________ Rhythm: _____________ Quality: ___________
Friction rub: _________
Murmur (describe location/ sounds):
________________________________________________________
______________________________________________________
Vascular bruit (location): ____________________
Jugular vein distention: _____________________
Breath sounds: location: ____________________
Description: ____________________________________________
Extremities:
temperature: ________ color:________ capillary refill: _______
Homans sign: _____________
varicosities (location): ___________________________________
Nail abnormalities: ______________________________________
edema(location/ severity +1to+4): __________________________
Distribution/ quality of hair: _______________________________
_____________________________________________________
Skin lesions: type:_______________________________________
location: _____________________________________________
color:_______________________________________________
Nursing Diagnosis:
________________________________________________________
________________________________________________________
_____________________________________________________
EGO INTEGRITY
Subjective (Reports)
Marital status: __________________________________________
Expression of concerns (e.g. financial, lifestyle or role changes):
_______________________________________________________
Stress factors: __________________________________________
Usual ways of handling stress: ____________________________
Ways of expressing feelings:
Anger: _______________________________________________
Anxiety: ______________________________________________
Fear: ________________________________________________
Grief: ________________________________________________
Others (hopelessness, helplessness, powerlessness): ______
_____________________________________________________
Cultural factors/ ethnic ties: ______________________________
Ethnic group: ___________________________________________
Religious affiliation: _____________________________________
Active/ Practicing: _______________________________________
Practices (prayer/meditation, etc.): _________________________
Religious/ Spiritual concerns: _____________________________
Desires clergy visit: _____________________________________
Expression of sense of connectedness/ harmony with self and
others: ________________________________________________

Medications/ Herbals: ___________________________________

_______________________________________________________
Objective (Exhibits)
Emotional status (check those that apply):
Calm: ______ Anxious:_________ Angry: _______________
Withdrawn: __________ Fearful: ______Irritable: __________
Restive: ________ Euphoric: ___________
Observed body language (e.g. pacing, fidgeting):
________________________________________________________
______________________________________________________
Observed physiological response (e.g. pallor, flushing):
________________________________________________________
______________________________________________________
Nursing Diagnosis: ______________________________________
________________________________________________________
______________________________________________________
ELIMINATION
Subjective (Reports)
Usual bowel elimination pattern: _____________
Character of stool: ______ Color of stool: _____________
Date of last BM and character of stool: (describe):
________________________________________________________
______________________________________________________
History of bleeding (describe): _____________________________
_______________________________________________________
Hemorrhoids/ Fistula: __________________________________
Constipation: acute: _________ chronic: ___________________
Diarrhea: acute: __________
chronic: _________________
Bowel incontinence:_____________________________________
Laxative: _______
how often: ________________________
Enema/ suppository: ___________ how often: ______________
Usual voiding pattern and character of urine: __________________
_______________________________________________________
Difficulty voiding: ______________________________________
Urgency: _____________________________________________
Bladder spasm: _______________________________________
Frequency:___________________________________________
Retention: ___________________________________________
Burning: _____________________________________________
Urinary incontinence (type/ time of day when it usually occurs):
_______________________________________________________
_______________________________________________________
History of kidney/ bladder disease:
_______________________
_______________________________________________________
Diuretic use: ________
Meds/Herbal:___________________________________________
_______________________________________________________
Objective (Exhibits)
Abdomen (palpation): Soft/ firm: __________________________
Tenderness/pain (quadrant/ location: _______________________
Distention: __________
Palpable mass/ location: __________
_______________________________________________________
size/ girth: _____________________________________________
Abdomen (auscultation):
bowel sounds (location/ type):
_______________________________________________________
Costovertebral Angle tenderness: _________________________
Bladder palpable: _______________________________________
Hemorrhoids/ fistulas: ___________________________________
Presence/ use of cathether or continence devices:
_______________________________________________________
Ostomy devices (describe appliance and location):
_______________________________________________________
Nursing Diagnosis: ______________________________________
________________________________________________________
______________________________________________________
FOOD/ FLUID
Subjective (Reports)
Usual food intake: _____________# of meals daily: _____snacks
(# and time consumed) ______

Page 7
2
Page

Dietary pattern/ content:

B: __________________________________________________
L: __________________________________________________
D: __________________________________________________
Snacks: _____________________________________________
Last meal consumed/ content: ___________________________
Food preferences: ______________________________________
Food allergies/ intolerances:
_______________________________________________________
Cultural or religious food preparation/ concerns/ prohibitions:
_______________________________________________________
Usual appetite: ____________________________________
Change in appetite: ______________________________________
Usual weight: __________Unexpected/ undesired weight loss/ gain:
__________________________________________________
Nausea/ vomiting: _______ related to: ______________________
Heartburn: _________
Indigestion: ___________
related to: ______________________________________________
relieved by: ____________________________________________
Chewing or swallowing problems:
Gag/ swallow reflex present: ______
Facial injury/ surgery: ____________
Stroke/ other neurological deficit:
_______________________
_____________________________________________________
Diabetes:______
Controlled with diet/pills/insulin: __________________________
Vitamin/ food supplements: ______________________________
Medication/ herbals: _____________________________________
Objective (Exhibits)
Current weight: _______ Height: _____________
Body built: ______________BMI: _____________
Skin turgor: ___________________
Mucous membranes (moist/ dry): _____________
Edema: generalized: _____ dependent: _____ feet/ ankles: _____
Periorbital:_________ abdominal/ascites: __________
Breath sounds (location/ adventitious sounds):
_______________________________________________________
_______________________________________________________
Condition of teeth/ gums: ________________________________
Dentures (full/partial): ____________________________________
Loose/ absent teeth/ poor dental care: ______________________
sore mouth/ gums: ______________________________________
Appearance of tongue: ___________________________________
mucous membranes: ____________________________________
Abdomen: bowel sounds (quadrant/
location): _____________________________________________
hernia/ masses: _______________________________________
Urine S/A or chemstix: ___________________________________
Serum glucose (glucometer): ___________________________
Nursing Diagnosis: ______________________________________
________________________________________________________
______________________________________________________
HYGIENE
Subjective (Reports)
Ability to carry out activities of daily living: independent/ dependent
(level 1= no assistance needed to 4= completely dependent):
__________
Mobility: Assistance needed (describe): ____________________
Assistance provided by: ________________________________
Equipment/ prosthetic devices required: __________________
_____________________________________________________
Feeding: ______________________________________________
Help with food preparation: ___________
Help with eating utensils: _____________
Hygiene:
Get supplies: ____________
Wash body or body parts: _____________
Can regulate bath water temperature: _______
Get in and out alone: ____________
Preferred time of personal care/ bath: _____________________
Dressing: ______________

Can select clothing and dress self: ______

Needs assistance with (describe): ________________________
Toileting: ______________________________________________
Can get to toilet or commode alone: ______
Needs assistance with (describe): ________________________
_____________________________________________________
Objective (Exhibits)
General appearance: Manner of dressing:
_______________________________________________________
Grooming/ Personal habits: _______________________________
Bath: __________________________________________________
Shampoo ______ Perineal Care _________
Oral Care _______________
Condition of hair/ scalp: __________________________________
Body odor: __________
Use of deodorant: _______________________________________
Presence of vermin (lice, scabies): _____________
Nursing Diagnosis: _________________________
________________________________________________________
______________________________________________________
NEUROSENSORY
Subjective (Reports)
History of brain injury, trauma, stroke (residual effects):
_______________________________________________________
Fainting spells/ dizziness: ________________________________
Headaches (location/type/frequency): ______________________
Tingling/ numbness/ weakness (location):
_______________________________________________________
Seizures: ______________________________________________
History or new onset seizures
Type: _________Frequency: ___________
Aura: __________
Postictal state: ________________________________________
How controlled: _______________________________________
Vision:
Loss or changes in vision: ______________________________
Date of last exam: _____________________________________
Glaucoma: _________
Cataract: _________
Eye Surgery (type/ date): ________________________________
Hearing loss: __________ Sudden or gradual: ______________
Date of last exam: _____________________________________
Sense of smell (changes): ________________________________
Sense of taste (changes): ________________________________
Epistaxis: ________ Other: _______________________________
Objective (Exhibits)
Mental status (note duration of change):______________________
______________________________________________________
Oriented/ disoriented: __________ Person: _______________
Place: _________________
Time: _________________
Situation: ____________________________________________
Check all that apply:
Alert: _______ Drowsy: ________ Lethargic: ______________
Stuporous: ______ Comatose: ____Cooperative: _____________
Combative: ___________ Agitated/ restless: _____________
Follows commands: ____________
Delusions (describe): ____________________________________
_______________________________________________________
Hallucinations (describe): _________________________________
_______________________________________________________
Affect (describe): ________________________________________
Speech: _______________________________________________
Memory
Recent: ______________________________________________
Remote: _____________________________________________
Glasgow Coma Scale: ___________________________________
Test
Score
EYE OPENING RESPONSE
SCORE
Spontaneously
4
To speech
3
To pain
2
None
1
MOTOR RESPONSE

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Page73

Obeys
Localizes
Withdraws
Abnormal flexion
Abnormal extension
None
VERBAL RESPONSE
Oriented
Confused
Inappropriate words
Incomprehensible
None
TOTAL SCORE

Deep tendon reflexes (present/ absent): ________

(encircle joint with abonormal reflex, then rate)

6
5
4
3
2
1
5
4
3
2
1
15

Cranial Nerves Assessment (describe result)

CN 1 : ________________________________________________
CN 2: ________________________________________________
CN 3:_________________________________________________
CN 4: ________________________________________________
CN 5: ________________________________________________
CN 6: ________________________________________________
CN 7: ________________________________________________
CN 8: ________________________________________________
CN 9: ________________________________________________
CN 10: _______________________________________________
CN 11: _______________________________________________
CN 12: _______________________________________________

Tremors: ________ Paralysis (R/L): _________

Posturing: _____________________________________________
Wears glasses: _______ Contacts: ___________
Hearing aids: _________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
PAIN/ DISCOMFORT
Subjective (Reports)
Location: _____ Quality: _________________________________
Intensity ( 1,2,3,4,5,6,7,8,9,10 ) ________________

Mini Mental Status Examination

Folstein Mini Mental Status Examination
Task

Instructions

Date
"Tell me the date?" Ask for
Orientation omitted items

One point each for

year, season, date,
day of week, and
month

Place
"Where are you?" Ask for
Orientation omitted items.

One point each for

state, county, town,
5
building, and floor or
room

Register 3
Objects

Name three objects slowly

and clearly. Ask the patient
to repeat them.

One point for each

item correctly
repeated

Serial
Sevens

Ask the patient to count

backwards from 100 by 7.
Stop after five answers. (Or
ask them to spell "world"
backwards.)

One point for each

correct answer (or
letter)

Recall 3
Objects

Ask the patient to recall the

objects mentioned above.

One point for each

item correctly
remembered

Naming

Point to your watch and ask

the patient "what is this?"
Repeat with a pencil.

One point for each

correct answer

Repeating
a Phrase

Ask the patient to say "no ifs, One point if

1
ands, or buts."
successful on first try

Give the patient a plain piece

of paper and say "Take this
Verbal
One point for each
paper in your right hand, fold
Commands
correct action
it in half, and put it on the
floor."

Show the patient a piece of

Written
paper with "CLOSE YOUR
Commands
EYES" printed on it.

Writing

Drawing

Scoring

Ask the patient to write a

sentence.

Radiation: ____________Frequency: __________

Precipitating factors: ____________________________________
Relieving factors : Pharmacologic: ________________________
Non-pharmacologic (e.g rubbing, rest, herbal) _____________
______________________________________________________
Associated symptoms: ___________________________________
Effect on: Daily activities: ________________________________
Relationships: ________________________________________
Job: _________________________________________________
Enjoyment of life: _____________________________________
Objective (Exhibits)
Grimacing: __________ Guarding affected area: ____________
Narrowed focus: ________________________________________
Emotional response (e.g crying, withdrawal, anger):
_______________________________________________________
Vital sign changes (acute pain): BP: ________ PR: ________
RR: _________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________

Scoring

One point if the

patient's eyes close

One point if sentence

has a subject, a verb, 1
and makes sense

One point if the

figure has ten
corners and two
Ask the patient to copy a pair intersecting lines
of intersecting pentagons
onto a piece of paper.
A score of 24 or above is considered normal.

30

RESPIRATION
Subjective (Reports)
Dyspnea related to: ______________________ Precipitating factors:
_________________
Relieving factors:
____________________
Cough (describe): __________________________ sputum (describe
character): _________________
Requires suctioning_________
History of (year): bronchitis: ____asthma: _____
emphysema: ____tuberculosis: __
recurrent
pneumonia: ______
exposure to noxious fumes/ allergens: ___
Infectious agents/ diseases/ poisons/ pesticides:
_______________________________________________________
Smoker: Yes: ___ No: ___
Type (e.g. menthol) ________ sticks/packs per day: ________
No. of Yrs: ____________
Use of respiratory aids: __________________________________
Oxygen (type/ frequency): ________________________________
Medications/ herbals: ____________________________________
_______________________________________________________
_______________________________________________________

Page
Page74

Objective (Exhibits)
Respirations
Spontaneous: Rate: __________ Depth: __________________
Assisted:__________ Parameters: ________________________
_____________________________________________________
O2 inhalation: _________ Type: ___________________________
Flow Rate: ____________________________________________
Chest excursion (equal/ unequal): _________________________
Fremitus: _____________________________________________
Use of accessory muscles: _______________________________
Nasal flaring: _______________________
Breath sounds: ________________________________________
Egophony:muffled: ___________ clear: ___________________
Skin/ mucous membrane color: ___________________________
clubbing of fingers: _____________
Sputum characteristics: ___________________ Pulse oximetry:
_________
Mentation (e.g. calm, anxious, restless):
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
SAFETY
Subjective (Reports)
Allergies/ sensitivity (medications, foods, environment, latex):
________________________________________________________
______________________________________________________
_______________________________________________________
Type of reaction: ________________________________________
_______________________________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
__________________________________________________
_____________________________________________________
Exposure to pollution, toxins, poisons/ pesticides, radiation
(describe reactions): ____________________________________
________________________________________________________
______________________________________________________
Living conditions (with whom/ location of residence):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Travelled Places: ________________________________________
_______________________________________________________
_______________________________________________________
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify): ______________________________________
Altered/ suppressed immune system (list cause):
________________________________________________________
______________________________________________________
_______________________________________________________
History of STD (date/ type): ______________________________
_______________________________________________________
test: __________________________________________________
High risk behaviours: ____________________________________
_______________________________________________________
Blood transfusion/ number: ___________ Type: _____________
Date: ______________________________
Reaction (describe): ___________________________________
_____________________________________________________
Use seat belt regularly: ____Bike helmets: ______
Other safety devices: ____________________________________
Work place safety/ health issues (describe):
_______________________________________________________
Currently working: ______
Rate working conditions (e.g. safety, noise, heating, water,
ventilation): ____________________________________________
_______________________________________________________

History of accidental injuries: _______________________________

_______________________________________________________
Skin problems (e.g. rashes, lesions, moles, breast lumps, enlarged
nodes) describe:
________________________________________________________
______________________________________________________
_______________________________________________________
Delayed healing (describe):
________________________________________________________
______________________________________________________
_______________________________________________________
Cognitive limitations (e.g. disorientation, confusion):
_______________________________________________________
Sensory limitations (e.g. impaired vision/ hearing, detecting hot/cold,
taste. Smell, touch):_______________________________________
_______________________________________________________
Prostheses: _______Ambulatory devices: _____________________
_______________________________________________________
Violence (episodes/ tendencies): ____________________________
_______________________________________________________
Objective (Exhibits)
Body temperature:__________
Skin integrity (e.g. scars, rashes, ulcerations, ulcerations, bruises,
blisters, burns degree/ %, drainage) / mark location on diagram:
_______________________________________________________

(Front)

(Back)

Results of testing (e.g. cultures, immune function, TB, hepatitis):

_______________________________________________________
_______________________________________________________
Nursing Diagnosis: _____________________________________
_______________________________________________________
_______________________________________________________
SEXUALITY (Component of Social Interaction)
Subjective (Reports)
Sexually active: _________
STI/ Birth control method: ________________________________
Sexual concerns/ difficulties (e.g. pain, relationship, role):
_______________________________________________________
Recent change in frequency/ interest:
_______________________________________________________
FEMALE: Subjective (Reports)
Menstruation
Age at menarche: __________________
Length of cycle: ____________________
Duration: __________________________
Number of pads/ tampons used/ day: _________
Last menstrual period: _______________
Bleeding between periods: ____________
Reproductive Infertility concerns: __________________________
Type of therapy (hormones): ______________________________
Pregnant now: _________ G: _____ P: _____ (TPAL): ________
EDD: ________________________________________________
History of Present Condition: (Start, list and describe symptoms
chronologically from time/day of onset onwards)
Initial: Wt: ________

Page 7
5

Vital signs: BP= _______ HR= ______

Temp. _______
Age of Gestation: _______________

RR= ________

Labor
1.Abdominal Status: FU: _____ EFW: ________ AOG: _________
a) Presence of uterine contraction:
frequency
duration
interval
intensity
b) IE Result:
time

Dilatn

Effacet

BOW
Cond.

station

discharges

Done By

Past Medical History

a.) Includes childhood illnesses (mumps, measles, german
measles, poliomyelitis, etc) ________________________
__________________________________________________
__________________________________________________
b) Any previous health care contacts- Include diagnostic test
results and date : u/a, cbc, bld. Typing, glucose screening
test, utz result: ______________________________________
___________________________________________________
c) Allergy- include food and drug hypersensitivity___________
___________________________________________________
d) Use of OTC/prescribed drugs __________________________
___________________________________________________
e) Past pregnancies:
No. Of
Preg.

Yr

Method
of Del.

Place of
del./attended by

Birth
wt

Condn

Condn of
baby

Prenatal History
d1) General physical and emotional state of the mother during
pregnancy ________________________________________
__________________________________________________
d2) Prenatal check up/consultations:
1st trimester (frequency):___________________________
Diagnostic & result: _____________________________
2nd trimester: _____________________________________
Diagnostic & result: _____________________________
3rd trimester: _____________________________________
Diagnostic & result: _____________________________
d3) Pregnancy complications & discomforts during present
pregnancy(if any)- nausea and vomiting: _______________
loss of appetite: ______ edema: ________ UTI : ________
co morbid illness: ______ Vagl bleeding: ____________
abnormal weight change: ______ HPN: _______
d4) Was pregnancy planned: Yes: ______ No: ______
when was quickening felt: __________________________
attitude of father: __________________________________
place where mother plans to give birth: _______________
_________________________________________________
Gynecologic History:
a.) Surgery affecting the: breast: _____ Mastectomy: _______
hysterectomy: _____ Hysterectomy: ______ TAHBSO :
b.) Ectopic pregnancy: _______
c.) Reproductive tract diseases: PID: ______
Polycystic ovarian disease: ______ H-mole : _____
Others: specify: __________________________________
d.)Breast:(symmetrical): ______ size and shape ______
retractions/ dimpling: ______ nipple discharge: _______
redness of the skin: _____ visible superficial veins_____ lumps
or masses on both breasts: _______ axillary lymph node mass:
_____ tenderness: __________
d.) Abdomen: (minimal) gravidarum striae: _______

(protruded) umbilicus______ fundic height: __________

tenderness: _______ (occasional/mild) uterine contractions:
________ fetal movement ______________
bowel sounds:
no. per minute
*Leopolds Maneuver:findings: describe:
LM I: __________________________________________
_______________________________________________
_______________________________________________
LM II: __________________________________________
_______________________________________________
_______________________________________________
LM III: _________________________________________
_______________________________________________
_______________________________________________
LM IV: _________________________________________
_______________________________________________
_______________________________________________
e.) Genitourinary tract:
(Darkly pigmented) inguinal region: _________________
vaginal secretions (watery or bloody): _______________
presence of haemorrhoids: ________________________
f.) Extremities: symmetrical length: _____________________
size upper and lower extremities: ___________________
edema: _______ varicosity: _____ limitation of ROM____
swelling of joints: ______ peripheral pulses: __________
tenderness: ______ claudication: ___________________
g.) Integumentary: gravidarum striae-: ____________________
specify location: ______ lesions: ______ rashes: ______
hematoma/petechiae: _____ chloasma: ______________
Post Partum
h.) Abdominal status:
location and size of the uterus: ______________________
condition of the uterus: ____________________________
i.)GUT status:presence of vaginal discharge: __________
amount: ____________ color: _______________________
condition of the perineum ( particularly if episiotomy is
done):____________________________________________
functioning of the bladder (time and amount of first urine, time
of first BM postpartum)_________________________
_________________________________________________
j.) Emotional/ Psychological Status
postpartum blues: ________ depression: _____________
heightened emotional reactions/labile moods: _________
_________________________________________________
Menopause: _____ onset: ____________
Hysterectomy/ Oophorectomy: ____________________________
Problem with: Vaginal lubrication: _____ hot flushes: ________
Vaginal discharge: ______ others: ________________________
Hormonal therapies: ___________________________________
Osteoporosis medications: ______________________________
Practices BSE: ____ Last mammogram: ____________________
Last Pap smear: _________ Results: _______________________
Objective (Exhibits)
Genitalia (warts/ lesions): _______
STI test results: _________________________________________
vaginal bleeding/ discharge: ________
Management: Meds: prescribed:___________________________
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

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MALE: Subjective (Reports)

Circumcised: ________
Practices self examination: Breast: _________
testicles: ________
Prostate disorder: _________
last prostocopic/ prostate exam: ____________
last PSA date: ______________
Medications/ herbals: ____________________________________
Objective (Exhibits)
Genitalia: Penis (circumcised): _______ warts/ lesions: ______
bleeding/ discharge: _______
Testicles (e.g. lumps): ________ Breast examination: ________
STI test results: _________________________________________
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
SOCIAL INTERACTIONS
Subjective (Reports)
Relationship status:
Single: _____ Married: _______
Separated/ Annulled/ Divorced: ________ Widowed: ______
Living with (Specify): ____________________________________
Yrs of Relationship:__________
Perception of relationship: _______________________________
Concerns/ stresses: _____________________________________
Role within family structure: ______________________________
Number/ Age of children: __________________
Perception of relationship with family members: _____________
_______________________________________________________
Extended family: ________________________________________
other support persons: __________________________________
Ethnic/ Cultural affiliations: _______________________________
Strength of ethnic identity: _______________________________
Feelings of (describe):
Mistrust: _____________________________________________
Rejection: ____________________________________________
Unhappiness: _________________________________________
Loneliness/ Isolation: __________________________________
Problems related to illness/ condition: ______________________
Problems with communication (e.g. speech, another language, brain
injury): ___________________________________________
Use of speech/ communication (list)_______________________
____________________________________________________
Is interpreter needed:Yes ______ No ______
Primary language: _________________________
Objective (Exhibits)
Communication/ speech: Clear: ______ Slurred: _______
Unintelligible: _____ Aphasic: ______
Unusual speech pattern/ impairment: _____
Laryngectomy present: _____
Family interaction (behavioural pattern)_____________________
_______________________________________________________
Nursing Diagnosis: _____________________________________
________________________________________________________
______________________________________________________
TEACHING/ LEARNING
Subjective (Reports)
Communication Dominant Language (specify):
_______________________________________________________
Second language: _______________________________________
Literate (reading/ writing): ______________
Educational level: _____________________________________
Learning disabilities (specify): ___________________________
Cognitive limitations: ____________________________________
Ethnic Affiliation: __________________________
Health and illness beliefs/practices/ customs: _______________
_______________________________________________________
Which family member makes healthcare decisions/ is spokesperson
for client: _________________________________
Presence of Advanced directives: _______ Code status: _______

Durable medical power of attorney: ___________

Designee: ____________________________________________
Health goals: ___________________________________________
Current health problem: client understanding of problem:
________________________________________________________
______________________________________________________
Special health concerns (e.g. impact of religious/ cultural practices):
_____________________________________________
_______________________________________________________
Familial risk factors (indicate relationship):
Diabetes: _____________ Thyroid (specify): ____________
Tuberculosis: ____________ Heart disease: __________
Stroke: __________________ Hypertension: ____________
Cancer: ________________ Kidney disease: ____________
Epilepsy/ seizures: ________
Mental illness/ depression: ___________
others: _______________________________________________
Vitamins: _________________ Herbals: ____________________
Street drugs: _________
Alcohol (amount/ frequency): ______________ Tobacco: ______
Smokeless tobacco: ______
Expectations of this hospitalization:
_______________________________________________________
Will admission cause any lifestyle changes (describe):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Evidence of failure to improve: ____________________________
_______________________________________________________
Date of last physical exam: _______________________________
Nursing Diagnosis: _____________________________________
_______________________________________________________
_______________________________________________________
DISCHARGE PLAN CONSIDERATIONS
Projected length of stay: ___________________ Anticipated date of
discharge:_______________
Date information obtained: ___________
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: _________________________
Homemaker/ maintenance (specify):
_______________________________________________________
Physical layout of home (specify):
_______________________________________________________
Referrals (date/ source/ services)
Social services: _______________________________________
Rehab services: _______________________________________
Dietary: ______________________________________________
Home care: ___________________________________________
Respiratory/ O2: _______________________________________
Equipment: ___________________________________________
Supplies: _____________________________________________
Other: _______________________________________________

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