Professional Documents
Culture Documents
MStool
MStool
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:
___________________________________________________
___________________________________________________
________
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: _________
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
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ROM: Describe:
__________________
_______________________________
_______________________________
_______________________________
Strength:
Lips:_________________ Sclera:
_________________________
Conjunctiva: ________________ Nailbeds:
__________________
Skin moisture (e.g. dry, diaphoretic):
_______________________
Blood pressure: lying:
R: _______ L Page 1
___________
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:_________________________________________
______
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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:
_____________________________________________
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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) ______
Dietary pattern/ content:
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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:
__________________________
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CN 8:
________________________________________________
CN 9:
________________________________________________
CN 10:
_______________________________________________
CN 11:
_______________________________________________
CN 12:
_______________________________________________
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 ) ________________
Instructions
Scoring
Date
"Tell me the date?" Ask for
Orientation omitted items
Place
"Where are you?" Ask for
Orientation omitted items.
Register 3
Objects
Serial
Sevens
Recall 3
Objects
Naming
Writing
Drawing
Scoring
30
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(Front)
(Back)
Dilat
n
Effac
et
BO
W
Con
d.
stati
on
discharg
es
Done By
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______________________________________________
_____
e) Past pregnancies:
No.
Of
Preg.
Yr
Meth
od of
Del.
Place of
del./attende
d by
Birt
h
wt
Cond
n
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:
_______________________________________________
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
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