PERSON ASSESSMENT

PSYCHOSOCIAL

Pre- Assessment Pathophysiogical Post-Assessment Pathophysiogic

Date Basis Date al Basis
time time
Type of
family:
Significant
Others:
Coping
Mechanism:
Religion:
Dialect:

Primary
Source of
Health Care:

Financial
Resources
Related to
Healthcare:

Occupation:

Educational .
Attainment:

General .
Appearance:

Tremors:

Motor Motor response

Glasgow response – –
Coma Scale
Verbal Verbal
response– response–

Eye opening – Eye opening –

Total: Total:
.

Affect

Orientation: Time
Oriented

Place

Person
.
Memory: ● Immediate
memory: ● Immediate
memory:
● Recent
memory: ● Recent
memory:
● Remote
memory: ● Remote
memory:

Speech:

Nonverbal
Behavior:

ELIMINATION

Stool: Pattern: Pattern:

Frequency: Frequency:
Consistency: Consistency:
Amount: Amount:
Color: Color:
presence of presence of
unusual odor: unusual odor:

Urine: Frequency: Frequency:

Quantity: Quantity:

Color: Color:

Clarity: Clarity:
Odor: Odor:

Laboratory Laboratory results:

results: Specific Gravity:
Specific Gravity: (+) albumin,
(+) albumin, glucose??
glucose??
 Abdomen: Contour: Contour:
Appearance: Appearance:
Palpation: Palpation:
-borborygmus/min: -borborygmus/min:

Use of abdominal Use of abdominal

muscles ? muscles ?

Toileting Independent/
Activity: Dependent??

REST AND ACTIVITY

Current
Activity Level: On wheelchair?? Complete bed
rest??

ADL’s:
Able to ____ Hygiene: Hygiene:
alone?
With Feeding: Feeding:
assistance?
Toileting: Toileting:

Ambulatin Ambulating
g :

grooming:
grooming Communica
: ting:

Communi
cating:

Sleep: Pattern: Pattern:

Quality: Quality:
Position: Position:
Body Frame:
Endomorph/
ectomorph/
mesomorph
Posture:

Gait:

Coordination:
Balance:
Muscle:
Strength:
-Right arm:
-Left arm:
-Right leg:
-Left leg:
involuntary
movements
like twitching
and spasm
and tics.??

Tone:

With
contractures a
shortening
arm?

Motor
function:
Fine:

Gross:
Range of
Motion: Arms
Extension Arms
Flexion
Abduction Knee
adduction Knee
Use of Device:
Use of Device:

Pain

P-
Q-
R-
S-
T-

Pain relief
measures:

SAFE ENVIRONMENT

Allergies/  Medicatio  Medication

Reactions: n- –
 Food –  Food –
 Environm  Environmen
ent – t–

Eyes/Vision:

Hearing/
Hearing Aid:

Skin integrity
 Skin color
Tone
Discoloration
Wounds

Temperature
Mucous  Oral  Oral mucosa:
Membrane: mucosa:

Temperature:

route

OXYGENATION

Activity
tolerance
Dependent?
Partially? Bed
rest?

Airway
Clearance

Oxygen
Saturation
Mouth

Lesions/
obstruction
O2? Running
at??
Nose
Lesions?
bump?
Nasal
cannula?
Respiration
Rhythm

use of
accessory
muscles

use of
abdominal
muscles
Lung Sounds
Depth
Position
Assumed
Color
Skin:
discolorations
Nails:
lips:
 Peripheral
Pulse
Rhythm:
Pulsation:
What artery:
Capillary
Refill

Blood
pressure
Edema
Homan’s sign
Oxygen
Therapy

NUTRITION

Height
Weight

Skin turgor

BMI/
Interpretation
BMI
Categories:
Underweight =
<18.5
Normal weight
= 18.5–24.9
Overweight =
25–29.9
Obesity = BMI
of 30 or
greater

Body type
Food YES NO YES NO
Tolerance/Abi
lity
A. Chew
B. Swallow
C. Tolerate
Food
D. Feed Self

E. Appetite
Amount

F. Gag reflex
Diet
Restrictions:
Hospital Diet:
Fluid Intake:
Intravenous Site: Site:
Fluids: Solution: Solution:
Drop Factor: Drop Factor: 1