Ateneo de Zamboanga University

College of Nursing

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: ___________________________ Attire:hospital gown

Personal Hygiene: ________________________________________________________
Gait: __________________ Posture: ___________ General Body Built: __________

BEHAVIOR
Level of Consciousness:
( / ) Awake ( ) Alert ( ) Lethargic
( ) Drowsy ( ) Stupurous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: __________________ Speech: minimal
Mood: uneasy Affect: __________________________

COGNITION

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

( ) Alert ( ) Restless ( ) Lethargic ( ) Comatose
Recent Memory: patient remember surgeon
Remote Memory: april 6, 2022

THOUGHT PROCESS

Thought Content: ( ) Logical ( /) Consistent

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

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( /) Normal ( ) Flushed ( ) Pale ( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others: _________________________
Texture: _______________________ Tone: _____________________________
Lesions: ( ) Yes, site: ______________ ( ) No
PALPATION
Moisture: yes Temperature: ______________________
Turgor: ___________________________
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(normal)
INSPECTION
Color: pink Texture: ______________ Configuration: ______________
Symmetry: ______________ Cleanliness: ______________

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: round
Hair Color: black Thinning: ( ) Yes ( / ) No
PALPATION-
Temporal Artery: _________
Cranium: _______________ Scalp: _______________
Hair Texture: _______________
Maxillary & Frontal Sinuses: __________________________

EYES
INSPECTION
Conjunctiva: R: _________ L: _________ Sclera: R: _________ L: _________
Cornea: R: _________ L: _________ Iris: R: _________ L: _________
Ptosis: R: _________ L: _________
Visual Fields: R: _________ L: _________
Extraocular movements: : R: _______ L: _______
Pupil: Color: R: _________ L: _________ Size: R: _________ L: _________
Response to Light & Accommodation: R: _________ L: _________

NOSE
INSPECTION
External Nose: __________________________
Nostrils: R: _________ L: _________

MOUTH
INSPECTION
Mouth & Throat Mucosa: normal Tongue: pink,not dry
Teeth and Gums: ____________________________
Floor of Mouth: _______________ Palate: _______________ Uvula: ______________
Lesions and Ulcers: ( ) Yes, site: ______________ ( /) No
Salivary Glands: (/)

FACE
INSPECTION
Spasms: ( ) Yes, site: __________ ( / ) No
Tics: ( ) Yes, site: __________ ( /) No
Lesions: ( ) Yes: ( ) Mild ( ) Moderate ( ) Severe ( / ) No
Facial Paralysis: ( ) Yes R: _________ L: _________ ( ) No

EARS
INSPECTION
Tympanic membrane: R: Intact ( ) Yes ( /) No L: Intact ( ) Yes ( ) No
Tragus of Ear: R: _________ L: _________
Canal: R: _________ L: _________
Lesions: ( ) Yes, site: ___________ ( / ) No
Discharges: ( ) Yes, amount: ________ ( ) Left ( ) Right ( ) Both ( /) No

NECK
PALPATION
Thyroid gland size: removed Shape: ________________
Tenderness: present Nodules: negative
Position of Trachea: intact
Cervical Lymph Nodes: negative

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 21
Pattern: ( ) Shallow ( ) Dyspnea ( ) Tachypnea ( ) Shortness of Breath
Chest Symmetry: ( /) Even ( ) Uneven
Chest Deformities: ( ) Scoliosis ( ) Kyphosis ( ) Kyposcoliosis
PALPATION
Chest: ( ) Masses, site: ____________
( ) Bulges, site: ____________

( ) Muscle Tone, site: ______________

( ) Crepitus, site: ______________
( ) Areas of Tenderness, site: ______________
( ) Subcutaneous Emphysema, site: ______________
Excursion: ( ) Respiratory: R: ______cms. L: ______cms.
PERCUSSION
Notes elicited: ______________ Site: __________________
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: ____________
( ) 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: ___________ Amount: __________
( ) Non-productive ( ) No

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

HEART
INSPECTION
Point of Maximal Impulse (PMI): ___________________
Thrills: ( ) Present ( ) Absent
PALPATION – Perfusion: Capillary Refill: _____seconds
Murmurs: ___________

PULSES
( ) Regular ( ) Strong ( ) Irregular ( ) Weak ( ) Absent
( ) Doppler ( ) Pacemaker
Radial: R: ____________ L: ____________
Pedal: R: ____________ L: ____________
Apical: R: ____________ L: ____________
BP: R: ____________ L: ____________
GASTROINTESTINAL SYSTEM
Mouth:___________________________________________________________________
Throat:___________________________________________________________________

ABDOMEN
INSPECTION
Contour: ____________________________ Symmetry:__________________________
Gastrostomy (specify): _____________________________________________________
AUSCULTATION
Bowel sounds: ( ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate:_________per minute
PERCUSSION
Notes: ____________________________ Site:__________________________________
PALPATION
Abdomen: ( ) Tender ( ) Soft/Non-Tender ( ) Firm ( ) Rigid
Mass: ( ) No ( ) Yes
Ascites: ( ) No ( ) Yes
Girth: ________________ Inguinal Area:__________________________

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry:___________________________ Deformities:________________________
Others: _________________
Peripheral pulses:
Upper Extremities: Radial: R: ____________ L: ____________
Ulnar: R: ____________ L: ____________
Brachial R: ____________ L: ____________
Lower Extremities: Popliteal: R: ____________ L: ____________
DorsalisPedis: R: ____________ L: ____________
Posterior Tibia:R: ____________ L: ____________
Edema: ( ) Yes ( )Pitting (Grade) _________ ( /) No
Temperature: ___________________________ Site: __________________________
RANGE OF MOTION: ( / ) Yes ( ) No, area: _________________
Deformity: none
Discrepancy in Extremity (Leg) Length ( )Yes ______________ ( / ) No
PALPATION
( ) Musculature ________________ ( ) Body articulation_____________________
( ) Crepitations ________________ ( ) Heat________________________________
( ) Swelling ____________________ ( ) Tenderness___________________________
Normal ROM of extremities: ( / ) Yes ( ) No
( ) Weakness ( Paresis) ( ) Paralysis
( ) Contractures ( ) Joint Swelling
( / ) Pain: ( ) Bone Pain ( ) Muscle Pain ( ) Joint Pain
( / ) Others: post-op site
Hand Grasps: ( / ) Equal ( ) Unequal ( )Weakness ( / ) R & L
Leg muscles: ( / ) Equal ( ) Unequal ( ) Weakness ( ) R & L

NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)

Optic Nerve (CN II)

Oculomotor (CN III)

Trochlear (CN IV)

Trigeminal Nerves (CN V)

Abducens Nerve (CN VI)

Facial Nerve (CN VII)

Acoustic Vestibulocochlear Nerve (CN VIII)

Glossopharyngeal Nerve (CN IX)

Vagus Nerve (CN X)

Spinal Accessory Nerve (CN XI)

Hypoglossal Nerve (CN XII)

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: ( ) Yes ( ) No
Detect Vibration: ( ) Yes ( ) No
Discriminate Light Touch: ( ) Yes ( ) No
Detect Temperature: ( ) Yes ( ) No
Detect Stereognosis: ( ) Yes ( ) No
Detect Graphesthesia: ( ) Yes ( ) No
Two-Point Discrimination: ( ) Yes ( ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
_____________________________________________________________________
_
Insertion Tendon of Triceps (C7 to C8)
_____________________________________________________________________
_
Insertion Tendon of Brachioradialis (C5 to C6)
_____________________________________________________________________
_
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_____________________________________________________________________
_
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
_____________________________________________________________________
_

SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

 _____________________________________________________________________
_
Cremasteric Reflex (L1 to L2)
_____________________________________________________________________
_
Plantar Reflex
_____________________________________________________________________
_

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: ________________________________________________________
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance: _____________________________________________
Bumps: ( ) Yes, site: ___________ ( ) No
Blisters: ( ) Yes, site: ___________ ( ) No
Lesions: ( ) Yes, site: ___________ ( ) No
Redness: ( ) Yes, site: ___________ ( ) No
Scrotum: R: ____________ L: ____________
Urine: Color: ______________________ Character: ____________________
Frequency per day: ___________ 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: 13 Length of Cycle: regular
Menopause: _____________________ Last Pap Smear: ____________________
Monthly Breast Self Examination ( / ) Yes( ) No
Method of Birth Control: _____________________________
Obstetrical History: G6 P6 A0 L6 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: normal stress/couple things
Coping Mechanism: none
Support System: family
Calm: (/ ) Yes____________________ ( ) No______________________
Anxious: ( ) Yes____________________ ( / ) No______________________
Angry: ( ) Yes____________________ ( / ) No______________________
Withdrawn: ( ) Yes____________________ (/ ) No______________________
Irritable: ( ) Yes____________________ ( / ) No______________________
Fearful: ( ) Yes____________________ ( / ) No______________________
Religion:_______________________________ Restrictions:_________________
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:___________ Weight: ___________ Height: ___________
Diet:________________ Meal Pattern:___________________________
( ) 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: - Characteristics: –
Last Bowel Movement: yesterday upon to surgery
NGT/ Gastrostomy:__________________

VENOUS ACCESS RECORD

Date Gauge (color)/ Date
# Site Fluid Reason
Inserted Number of Drops Removed

PAIN ASSESSMENT
Location of pain: goiter abdominal Frequency: —-
Intensity Pain Scale(0-10): 5 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
( ) Ordered Therapies
( ) Diagnosis / Disease
( ) Pain Management
( ) Hospital Referrals
( ) Community Referral
( ) Medication
( ) Signs & Symptoms to Report
( ) Lifestyle Change
( ) Rehabilitation Measures
( ) Hygiene / Self care
( ) Diet or Nutrition
( ) Mobility / Ambulation

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.
__________________________________________________________________________
__________________________________________________________________________
_______________________________________________________________________