Ateneo de Zamboanga University

College of Nursing

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: Clean Attire: T-shirt and pants

Personal Hygiene: Good personal hygiene
Gait: Broad-based gait for support Posture: Erect General Body Built: Skinny

BEHAVIOR
Level of Consciousness:
( ) Awake ( ) Alert ( ) Lethargic
( ) Drowsy ( ) Stupurous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: Stoic Speech: Can speak 2 to 3 phrases or sentences
Mood: Moody, sometimes happy or sad Affect: Food, toys, presence of parents

COGNITION

Oriented: ( )Person ( ) Place ( ) Time ( ) Confused ( ) Sedated

( ) Alert ( ) Restless ( ) Lethargic ( ) Comatose
Recent Memory: Eating at home with parents
Remote memory: Playing on playground with friends
THOUGHT PROCESS

Thought Content: ( ) Logical ( ) Disorganized

Client’s Perceptions: ( ) Reality-base ( ) Congruent with others
( ) Others: Imaginative
Suicidal Thoughts/Ideation: ( ) Present ( ) Absent

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( ) Normal ( ) Flushed ( ) Pale ( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others: _________________________
Texture: Transparent skin, smooth Tone: White
Lesions: ( ) Yes, site: ______________ ( ) No
PALPATION
Moisture: Dry sometimes Temperature: 38.6 C
Turgor: Skin folds retracts immediately
Edema: ( ) Absent ( ) Present, site: _______________________
( ) Mild ( ) Moderate ( ) Severe
Pruritus: ( ) Yes, site: _________________ ( ) No
Wound incision/pressure sore site: ______________ Dressing type: ______________
Odor: ( ) None ( ) Mild ( ) Foul
Drainage/Exudates: ( ) Serous ( ) Sanguinous ( ) Serosanguinous
Color: ( ) Yellow ( ) Creamy ( ) Green ( ) Beige/tan

NAILS
INSPECTION
Color: Wite, transparent Texture: Hard
Symmetry: Symmetrical Cleanliness: Clean and neat
HEAD AND NECK
HEAD
INSPECTION
Head Structure and symmetry: Oval and symmetrical
Hair Color: Black Thinning: ( ) Yes ( ) No
PALPATION
Temporal Artery: Absent
Cranium: without intention Scalp: Dry without rashes or wounds
Hair Texture: Smooth

NECK
PALPATION
Thyroid gland size: within normal Shape: long
Tenderness: absent Nodules: absent
Position of Trachea: within normal

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 60 breathes/min
Pattern: ( ) Shallow ( ) Dyspnea ( ) Tachypnea ( ) Shortness of Breath
Chest Symmetry: ( ) Even ( ) Uneven
AUSCULTATION
Excursion: ( ) Diaphragmatic: R: ______cms. L: ______cms.
Breath Sounds:
Normal: ( ) Bronchial ( ) Bronchovesicular ( ) Vesicular
Adventitious: ( ) Crackles-Coarse, site: ____________
( ) Crackles-Fine, site: ____________
( ) Stridor, site: ____________
( ) Rhonchi/Gurgles, site: ____________
( ) Wheezes, site: right lung
( ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
( ) Bronchophony ( ) Egophony ( ) Whispered
( )Pecteriloquy ( ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough: ( ) Yes: Type: ( ) Productive:
Color of Sputum: yellow Amount: moderate amount
( ) Non-productive ( ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
AUSCULTATION
Carotid Arteries: Bruits: ( ) Absent ( ) Present
Jugular Vein Distention: ( ) Yes: _______cms. ( ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): 2-3 cm
Thrills: ( ) Present ( ) Absent
PALPATION – Perfusion: Capillary Refill: 2 seconds
Murmurs: absent

PULSES
( ) Regular ( ) Strong ( ) Irregular ( ) Weak ( ) Absent
( ) Doppler ( ) Pacemaker
Radial: 90 beats/min
Pedal: 90 beats/min
Apical: 160 beats/ min
BP: 110/55 mmHg
GASTROINTESTINAL SYSTEM
Mouth: Pink, smooth
Throat: Normal, no nodes

ABDOMEN
INSPECTION
Contour: EVEN Symmetry: symmetrical
AUSCULTATION
Bowel sounds: ( ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate: 30 per minute

PALPATION
Abdomen: ( ) Tender ( ) Soft/Non-Tender ( ) Firm ( ) Rigid
Mass: ( ) No ( ) Yes
Ascites: ( ) No ( ) Yes

GENITOURINARY
PERIANAL REGION
INSPECTION

( ) Hemorrhoids: ( ) Bleeding ( ) Not

( ) Fissures ( ) Scars ( ) Lesions ( ) Rectal Prolapse
( ) Fistula ( ) Discharge ( ) Blood in stool

PALPATION
( ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution: Absent
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance: normal in color and texture
Bumps: ( ) Yes, site: ___________ ( ) No
Blisters: ( ) Yes, site: ___________ ( ) No
Lesions: ( ) Yes, site: ___________ ( ) No
Redness: ( ) Yes, site: ___________ ( ) No
Scrotum: Normal texture and color
Urine: Color: bright yellow
Frequency per day: 2-3 times Amount: moderate amount
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Others (specify): _________________________

FEMALE GENITALIA
INSPECTION
Mons Pubis: _______________________ Labia Majora: ______________________
Labia Minora: _____________________ Clitoris:
____________________________
Vagina: ___________________________ Urinary Meatus: ____________________
Skene’s and Bartholin’s Glands: ____________________________________________
Urine: Color: ______________________ Character: _____________________
Frequency per day: ___________ Amount: ______________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Other:_________________________
LMP: _________________________________ ( ) Vaginal Discharges: ___________
Menstrual Problems:
( ) Amenorrhea ( ) Dysmenorrhea ( ) Menorrhagia
( ) Metrorrhagia ( ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche: ________________ Length of Cycle: ____________________
Menopause: _____________________ Last Pap Smear: ____________________
Monthly Breast Self Examination ( ) Yes ( ) No
Method of Birth Control: _____________________________
Obstetrical History: G___ P___A___L___ AOG______
POP: ______ Weight: ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: _____________________
Urine Test Result: ___________________ Pregnancy Test: ___________________
( ) Albumin _______ ( ) Sugar ________
( ) Protein _______ ( ) RBC ________ ( ) Pus ________
Bleeding: ( ) Yes, amount: ___________ ( ) No
Uterine Discharges:
Rubra: Color_______ Amount________ Odor_________
Serosa: Color_______ Amount________ Odor_________
Alba: Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: pain from the illness
Coping Mechanism: toys, foods and presence of parents and siblings
Support System: family
Calm: ( ) Yes____________________ ( ) No______________________
Anxious: ( ) Yes____________________ ( ) No______________________
Angry: ( ) Yes____________________ ( ) No______________________
Withdrawn: ( ) Yes____________________ ( ) No______________________
Irritable: ( ) Yes____________________ ( ) No______________________
Fearful: ( ) Yes____________________ ( ) No______________________
Religion: Christianity Restrictions: Limited sweets
Feeling of Helplessness: ( ) Yes ( ) No
Feeling of Hopelessness: ( ) Yes ( ) No
Feeling of Powerlessness: ( ) Yes ( ) No
Tobacco Use: ( ) Yes____________________ ( ) No______________________
Alcohol Use: ( ) Yes____________________ ( ) No______________________
Drug Use: ( ) Yes____________________ ( ) No______________________

NUTRITION
General Appearance: ( ) Well Nourished ( ) Malnourished
( )Emaniciated ( ) Other
Body Built: skinny Weight: 8kg Height: 33 inches
Diet: Normal diet Meal Pattern: eats meal 3x a day
( ) Feeds Self ( ) Assist ( ) Total Feed

Mastication/Swallowing Problem ( ) Yes_________ ( ) No_________

Dentures: ( ) Yes ( ) No
Appetite: ( ) Increased ( ) Decreased ( ) Unusual
Decreased Taste Sensation: ( ) Yes ( ) No
Nausea: ( ) Yes ( ) No
Stool frequency: once a day Characteristics: hard stool
Last Bowel Movement: last 2 days ago
NGT/ Gastrostomy: N/A
 VENOUS ACCESS RECORD
Date Gauge (color)/ Date
# Site Fluid Reason
Inserted Number of Drops Removed

PAIN ASSESSMENT
Location of pain: _____________________ Frequency: __________________
Intensity Pain Scale(0-10): ___________________ Quality: _____________________
Onset: (When did your pain started?) ______________________________________
Duration:_______________________ Body Reaction: __________________________
Alleviating Factors: _______________________________________________________
Precipitating factors:______________________________________________________
Special Assessment Devices
( ) Wheelchair ( ) Contacts ( ) Venous Access device
( ) Braces ( ) Hearing aid ( ) Epidural catheter
( ) Cane/ Crutches ( ) Prosthesis ( ) Walker
( ) Glasses
Others:____________________________________________________________________
___________________________________

SELF-CARE
Need Assist With:
( ) Ambulating ( ) Elimination
( ) Bed Mobility ( ) Meals
( ) Hygiene ( ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Use ( ) Signs & Symptoms to Report
( ) Ordered Therapies ( ) Lifestyle Change
( ) Diagnosis / Disease ( ) Rehabilitation Measures
( ) Pain Management ( ) Hygiene / Self care
( ) Hospital Referrals ( ) Diet or Nutrition
( ) Community Referral ( ) Mobility / Ambulation
( ) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with special nursing
care instruction to be given to the client like, dosage, time, frequency.
 Paracetamol 60 mg/kg/day every 4 hours
 Cefuroxime 40 mg/kg/day every 8 hours
 Guaifenessin 300 mg/dose every 4 hours
 Nebulization with Salbutamol 5mg/2.5 ml every 4 hours