8/22/2019 2- Assessment Form

1/9

Inter American University of Puerto RicoMetropolitan Campus

Science and Technology FacultyCarmen Torres de Tiburcio School of Nursing

Nursing Assessment form

Clients name __________________________________ Students name ____________________________________________________

Subjective Data Objective Data

*Health perception- health management pattern*

Date of birth ______________________ Ethnic background_________________________Religion _________________________ Age _________ Sex________________________Education level_____________________________________________________________Past treatments_________________________________________________________________________________________________________________________________________________________________________________________________________________

Previous hospitalizations _________________________________________________________________________________________________________________________________________________________________________________________________________

Health episode during this year (or previously) ______________________________________________________________________________________________________________Actions taken when the symptoms appear: _________________________________________________________________________________________________________________Obtained results: _____________________________________________________________________________________________________________________________________

Reasons to searching health care services________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medical diagnosis__________________________________________________________________________________________________________________________________

Current treatment _____________________________________________________________________________________________________________________________________

Medical diagnosis ___________________________________________________________

__________________________________________________________

__________________________________________________________

Medication taken now

Name Dosage Use

8/22/2019 2- Assessment Form

2/9

2

Subjective Data Objective Data

Medication taken now

Laboratory results:

CBC

Indicators Clients results Normal values

Hemoglobin

Hematocrit

RBC

WBC

Platelets

U/A

Indicators Clients results Normal values

Color

Turbidity

pH

Specific gravity

Protein

Glucose

Ketones

Microscopicexamination

RBCWBCBacteria/yeast

See page 1084(Cravens FUNDAMENTALS OF NURSING textbook).

Name Dosage Use

How healthy is the client ( circle) 1 2 3Poor Regular Excellent

Health perception (description of health state) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Effect of the disease onADL__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Use of : Alcohol_________________________________________________________

Tobacco ________________________________________________________Drugs _________________________________________________________

Particular health habits:Use of medication in the home ________________________________________________________________________________________________________

Activities done to maintain a healthy body _______________________________________________________________________________________________________________________________________________________________________

8/22/2019 2- Assessment Form

3/9

3

Subjective Data Objective Data

Home remedies used________________________________________________________________________________________________________________________________________________________________________________________

Last immunizations____________________________________________________________________________________________________________________________Do you comply with the prescribed treatment: Yes_____________ No ______________Difficulty to follow the therapeutic treatment___________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other laboratory results:

Indicators Clients results Normal values

*Activity-exercise health pattern*

Daily activities: (use the code)Hygiene ______________________________________________________________

Cooking_______________________________________________________________Bathing ______________________________________________________________Movement____________________________________________________________Dressing ______________________________________________________________Doing shopping ________________________________________________________Doing house chores _____________________________________________________Working in the yard _____________________________________________________Time to eat ____________________________________________________________Moving in the bed_______________________________________________________Combing your hair ______________________________________________________Applying makeup _______________________________________________________Cleaning the house_____________________________________________________

Disnea________________________ Palpitations____________________________Chest pain ________________ Weakness __________________________________Body pain _______ Location of the pain ___________________________________

Describe the pain:Location_________________________________________________________Intensity _________________________________________________________Irradiacin _________________________________________________________Relief ____________________________________________________________Duration_________________________________________________________

Description _____________________________________________ Difficulty/rigidity when moving ___________________________________________

______________________________________________________________________

Cardio-respiratory system:Peripheral pulses:

Carotid ______________________________________________________________________________________________________________________________________Radial _________________________________________________________________

_______________________________________________________________________Brachial _______________________________________________________________________________________________________________________________________Popliteal ______________________________________________________________

_______________________________________________________________________Femoral _______________________________________________________________________________________________________________________________________Pedal ________________________________________________________________________________________________________________________________

Tibial posterior__________________________________________________________________________________________________________________________________

Apical pulse _____________________________________________________________________________________________________________________________________

Respiratory system:R.________________________________________________________________________

________________________________________________________________________________________________________________________________________________Symmetry of thoracic movement_________________________________________________________________________________________________________________________

Retractions _______________________________________________________________Sensibility to the touch ______________________________________________________

8/22/2019 2- Assessment Form

4/9

4

Subjective Data Objective Data

Resting activities (hobbies)____________________________________________________________________________________________________________________________________________________________________________________________Exercise routine _____________________________________________________

______________________________________________________________________Occupation ___________________________________________________________

______________________________________________________________________

______________________________________________________________________What effect has the disease had on the activities of daily living (ADL)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Breaths with his/her mouth open ____________________Searches for a good position to breath _______________`Describes sounds produced when breathing ______________________________________Cough present_____________________________________________________________Productive cough ___________________________________________________________

Blood Pressure

Sitting R_____________________________ L_________________________Laying down R_____________________________ L_________________________Standing R _____________________________ L ________________________

Musculoesqueletal:Posture __________________________________________________________________Alignment _______________________________________________________________________________________________________________________________________Simmetry_________________________________________________________________________________________________________________________________________Way of walking ___________________________________________________________________________________________________________________________________

Balance __________________________________________________________________________________________________________________________________________

Coordinated movements ___________________________________________________________________________________________________________________________ROM ___________________________________________________________________________________________________________________________________________

In the following diagram circle the area with limited movement

8/22/2019 2- Assessment Form

5/9

5

Subjective Data Objective Data

*Nutritional-metabolic health pattern*

Daily consumption of food and liquids (Take the nutritional history of 24 hours)Breakfast _____________________________________________________________

______________________________________________________________Lunch________________________________________________________________

______________________________________________________________

Dinner ____________________________________________________________________________________________________________________________

Snacks _____________________________________________________________________________________________________________________________

Consumption of liquids ___________________________________________________Nutrional supplements consumed ________________________________________________________________________________________________________________Food intolerance ______________________________________________________________________________________________________________________________Foods you do not like __________________________________________________________________________________________________________________________Difficulty to chew ________________________________________________________

Disphagia ( difficulty to swallow) ___________________________________________Problems with the gums ________________________________________________________________________________________________________________________Problems with the tongue _________________________________________________Dental problems ______________________________________________________________________________________________________________________________Others problems when eating al ___________________________________________Have you lost weight: Yes ____ No___ Have you gained weight: Si _____ No ______How much?__________ Difficulty in gaining weight _____________________________Difficulty in losing weight _________________________________________________Description of the appetite _____________________________________________________________________________________________________________________

Nausea and vomiting ____________________________________________________Abdominal pain ________________________________________________________Use of antacids ________________________________________________________Use of laxatives ________________________________________________________Problems with theskin_______________________________________________________________________________________________________________________________________Wound healing _________________________________________________________Problems with the hair__________________________________________________________________________________________________________________________Problems with the nails ___________________________________________________Intolerance to cold and heat _______________________________________________

_____________________________________________________________________

Appearance___________________________________________________________________________________________________________________________________________Personal care ______________________________________________________________________________________________________________________________________Posture____________________________________________________________________

Facial expression____________________________________________________________________________________________________________________________________Temperature ______________________________________________________________Skin: Color__________________________________________________________________

Texture ________________________________________________________________Temperature ____________________________________________________________Humidity _____________________________________________________________Turgor _________________________________________________________________Sensibility to the touch____________________________________________________

Red areas: Circle the affected area in the following diagram

Hair: Color _________________________________________________________________Amount ________________________ Texture_______________________________Distribution____________________________________________________________

Nails: Color ______________________ Condition _________________________________Texture ______________________________________________________________

Mouth: Condition of the oral mucosa_________________________________________________________________________________________________________________# of teeth _____________ Cavities ___________________________________Absent teeth _______________ (Mark in the following diagram)

Top * Bottom *

8/22/2019 2- Assessment Form

6/9

6

Subjective Data Objective Data

Changes in the voice ____________________________________________________Difficulty with strength or vigor___________________________________________________________________________________________________________________

Teeth condition_______________________________________________________________________________________________________________________Gums_____________________________________________________________________________________________________________________________________Tongue ___________________________________________________________________________________________________________________________________

*Elimination health pattern*Fecal elimination habits:Frequency ____________________ Color ___________________________________Odor __________________________Consistency_____________________________Form________________________________________ Pain____________________Cosntipation___________________________________________________________Use of enemas _________________________________________________________Use of suppositories______________________________________________________Use of laxatives ________________________________________________________Stool softener __________________________________________________________Constant or frequent diarrhea ___________________Odor_______________________Medication used for diarrhea _____________________________________________

______________________________________________________________________Ileostomy________________________ Colostomy ______________________

Urinary elimination habits:Frequency ______________________ Amount _______________________________Color ________________________ Odor ___________________________________Pain _______________________ Incontinency _______________________________Nocturia _____________________ Retention ________________________________Enuresis ______________________ Hematuria _______________________________Urgency_________________________ Frequency___________________________Difficulty when urinating __________________________________________________Urinary deviation______________________________________________________

Infections_____________________________________________________________Catheter (Foley) ___________Type_________________________________________

Excessive perspiration: Yes ______ No _____ In which circumstance? _____________

_____________________________________________________________________

Problems with bad breath ________________________________________________

_____________________________________________________________________

Use of diuretics ________________________________________________________

Abdomen :Contour __________________________________________________________________Belly button ________________________________________________________________Pronounced veins__________________________________________________________Anus:Rashes ____________________________________________________________________Lesions ___________________________________________________________________Sensitive to the touch _______________________________________________________Miccions:Amount ____________________ Color ____________________________Odor ____________________________________ Pain _______________________

Additional description:__________________________________________________________________________________________________________________________________Hematuria __________________________________________________________________Piuria ________________ Oliguria ______________________________________________Urinary deviations ___________________________________________________________Defecation:Color ______________________________________________________________________Odor _______________ Consistency ____________________________________________Form _____________________________________________________________________Pain______________________________________________________________________Constipation _______________________________________________________________Bleeding (Dark stools ________________________________________________________

Diarrhea ______________________________________Odor_________________________Medication used for diarrhea______________________________________________________________________________________________________________________________Ileostomy __________________________Colostomy _______________________________Medication used for constipation__________ ______________________________________Laboratories:

Indicators Clients results Normal values

8/22/2019 2- Assessment Form

7/9

7

Subjective Data Objective Data

* Sleep-rest health pattern*

Hours of sleep ____________ Quality ______________________________________Expresses not having slept well _____________________________________________Expresses being tired ____________________________________________________Difficulty in falling asleep en _______________________________________________

Difficulty in staying asleep______ ___________________________________________Awake early in the morning Yes ______ No ______Difficulty in falling to sleep again Yes _______ No _________

Help to fall asleep ______________________________________________________Medications used to fall asleep ____________________________________________Nightmares ________________________________________________________Do you wake up early _____________________________________________Do you take a nap? Yes_____ No____ Frequency ___________ Duration_______

Appearance : Bags under the eyes _____ Yawning ____ Sleepy ________Do your eyes close? ____________ Do you fall asleep while talking? _________________Looks tired _________________________________________________________Slow to respond:_________________________________________________________

Difficulty in finding the right words ______________________________________________Irritability ____________ Bad temper ________________ Low tolerance point __________Short attention span__________________________________________________________Sleepy _________________________________________________________________

Impaired concentration ______________________________________________________

*Cognitive-perceptual health pattern*

Perception of:Vision:

Difficulty with vision____________________________________________________________________________________________________________________________Visual aids : Glasses _____ Contact lenses______ Others ____________________________________________________________________________________Eye surgery________________________________________________________Tears ____________________________ Hot_____________________________Secretions ___________________________________________________________Last visit to the ophthalmologist_____________________________________________Hearing:Difficulty in hearing____________________________________________________Right ear: Deafness : _________ Secretions____________________________________________________________________________________________________

Pain _________________________________________________________________Left ear: Deafness __________Secretions ____________________________________________________ Pain ___________________________________________Hearing aids________________________________________________________Ear surgery ________________________________________________________Taste :Difficulty with tasting foods_________________________________________________Smell:Difficulty with smell_______________________________________________________Sensation on the skin:Difficulty with sensation on the skin __________________________________________Sensitivity to the touch ___________________________________________________

Loss of sensation ____________________________________________________Pain _________________________________________________________________

Use of glasses /visual aids______________________________________________Secretions _________________________________________________________

Use de hearing aids _________________________________________________________

Secretions ________________________________________________________

Smell test _____________________________________________________________

Taste test _____________________________________________________________

Reaction to the changes in temperature __________________________________________

__________________________________________________________________________

Lost of sensation ________________________________________________________

Sensitive to the touch Yes _________ No _________ Location ______________________

__________________________________________________________________________

Scale of pain ______________________________________

Facial expression of pain: _______________________________________________________________________________________________________________________________Corporal expression of pain: ___________________________________________________Characteristics of the pain: _____________________________________________________

____________________________________________________________________________________________________________________________________________________

__________________________________________________________________________

8/22/2019 2- Assessment Form

8/9

8

Subjective Data Objective Data

Location _______________________________________________________Intensity _________________________________________________________Iradiation _________________________________________________________Relief ____________________________________________________________Duration _________________________________________________________Description _______________________________________________________

Understanding of the disease__ __________________________________________________________________________________________________________________Understanding of the treatment ___________________________________________________________________________________________________________________Ability to express him/herself ____________________________________________________________________________________________________________________Recent changes in memory ______________________________________________________________________________________________________________________Ability to remember :

Past ___________________________________________________________Present __________________________________________________________

Ability to make decisions_____ _________________________________________________________________________________________________________________Expression of feelings ______________________________________________________________________________________________________________________Method of learning : Listening _________________ Reading __________________

Observing ___________

Thinking process:Alert ___________________________________________________________________Conscious _______________________________________________________________Coherent ________________________________________________________________

Orientation: Person ____________ Time __________ Place _____________________Understanding of the disease __________________________________________________________________________________________________________________________Understanding of the treatment __________________________________________________________________________________________________________________________Ability to express him/herself _____________________________________________________________________________________________________________________________Ability to remember :

Recent________________________________________________________________Past ________________________________________________________________

Ability to make decisions _______________________________________________________________________________________________________________________________Expression of feelings ____________________________________________________Reads ____________________________________________________________________

*PATTERN OF BELIEFS AND VALUES*

Orientation of cultural values:

Orientation Associated values

Person-nature

Control Subdued Harmony

Control Fatality Equilibrium

Order Fears Balance

Plans Survival Integration

Time Future Present Past

Management Wonder Tradition

Achievement Flexibility Ritual

Investigation Pleasure of the senses ObligationRelationships Individual Collateral Linear

Independence Mutual responsibility Authority

Competition Belonging Discipline

Success Hierarchy

Activities DO BE Becoming

Religious artifacts present ________________________________________________________________________________________________________________________________________________________________________________________________________Particular items present ____________________________________________

____________________________________________________________________________________________________________________________________________________Religious activities ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Visits from the clergy __________________________________________________________________________________________________________________________________

Visits from other groups of people______________________________________________

__________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

8/22/2019 2- Assessment Form

9/9

9

Subjective Data Objective Data

Productivity Being oneself Self-actualization

Efficiency Eloquence Total

Earningmoney

Celebration Search /meaning

Other values: Education ___________ Participate in religious activities ____________

Exercise __________________ Socialization __________________________Other values ____________________________________________________

____________________________________________________________Goals _______________________________________________________________________________________________________________________________________Source of hope / strengths_____________________________________________________________________________________________________________________________________________________________________________________________Significant religious people in your life __________________________________________________________________________________________________________________________________________________________________________________Religious practices ______________________________________________________

____________________________________________________________________________________________________________________________________________Cultural assessment:Language __________________________________________________________Religion_______________________________________________________Relationship with God _______________________________________________________________________________________________________________________`

Individual preferences ______________________________Touch _____________________________________________People ( quantity, sex y civil status) permitted during the process of thedisease __________________________________________Clothes ____________________________________________________

Food and liquids___________________________________________Activity during the disease _____________________________Position ________________________________________________Privacy_______________________________________________

__________________________________________________________________________Food _________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Clothing __________________________________________________________________

__________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Lighting ____________________________________________________________________

__________________________________________________________________________

Temperature of the area ____________________________________________________

__________________________________________________________________________

Taken by __________________________________________________________________________________

Bibliography: Example of a Health Assessment Form Organized By Functional Health Patterns.From Weber, J. (1992). Nurses Handbook Of Health Assessment, 2nd ed. Philadelphia: J. B. Lippincott.A.Piazza y C. Padilla / Febrero 2003. Rev. 2008Translated to English (2nd time) by R. Camacho // SEP 2008