Filamer Christian University

COLLEGE OF NURSING
Roxas Avenue, Roxas City, 5800

NURSING ASSESSMENT SHEET

Document Name: Nursing Assessment Sheet Effectivity: January 15, 2023
Document No. CN-2019-C1-018 Issuing Office: CN Office
Revision No. 1 Page No. 1

Name of Student: ________________________________ Level/ Section: __________ Group No:

__________
Area of Exposure: _________________ Shift: ______ Week/Date
Period:______________________________

I. Biographical Data
Patients Initials: ___________________ Sex: _______ Civil Status:
________________________________
Age: ___________ Birthday: _____________________ Birthplace:
________________________________
Adress: ________________________________________ Religion:
__________________________________
Race or Ethnic Background: ________________________ Nationality: ___________________-
_____________
Educational Level: _______________________________ Occupation:
_______________________________
Who lives with the client: _________________________ Attending Physician: _______________________
Admission Data:
Data: _______________________ Time: _________ Room/Ward:
_______________________________
Source of History/Data:
Primary Source: ________________________________ Date of Interview:
___________________________
Secondary Source: _____________________________ Time of Interview:
___________________________

II. Health History

A. Chief Complaint
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B. Admitting Impression
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C. History of Present Illness

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D. Past Health History

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E. Family Health History (may list down as many as reported)

Heredofamilial Diseases Paternal Maternal

F. Socio-Cultural History
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G. Environmental History
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H. Medications and Substance Used

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I. Obstetrical History (For OB-Gyne Cases)

Pre-partum
Age of Menarche: _________ Menstrual Cycle (days): __________ Duration of menstruation:
____________
Interval of menstruation: _________________________________ Number of pads used: ________________

Intra-partum
Gravity/Parity: __________ Type of Delivery: ___________________________________ AOG:
___________
Fundic Height: __________ Contractions (Duration/Interval/Frequency): _______________________________
Fetal Heart Rate: ________ Fetal Position: _____________________ Fetal Presentation:
_________________

Post-partum
Gravity/Parity: __________________ Type of Delivery:
____________________________________________
Lochia: ________________________ Type of Episiotomy:
__________________________________________

II. Infant’s Development Milestones (For Pediatric Cases Only)

Age Gross Motor Fine Motor Communication/ Social

0–3
Months

4–6
Months

7–9
Months

10 – 12
Months

III. Pattern of Functioning

Pattern Area Before Hospitalization After Hospitalization

Fluid & Nutrition

Elimination

Activity & Exercise

 Rest & Sleep

IV. Laboratory Test and Diagnostic Examinations (Add extra sheets following this format if needed)

Type of Laboratory Test: _________________________________ Date of Test:

_________________________

Test Normal Values Patients Values Significance

Type of Laboratory Test: _________________________________ Date of Test:

_________________________

Test Normal Values Patients Values Significance

Type of Laboratory Test: _________________________________ Date of Test:

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Test Normal Values Patients Values Significance

Type of Diagnostic Exam: ___________________________________ Date of Exams:

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Result/Impression:____________________________________________________________________________
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V. General Survey
Vital Signs: T: _________ BP: _________ PR: _________ RR: _________ Height: _______ Weight:
________
Speech: _____________ Gait: ____________ Posture: ___________ Emotional State:
___________________
Mental State: __________________________________ Grooming/ Hygiene:
____________________________
VI. Physical Assessment (Cephalocaudal)

Body Parts Inspection Palpation Percussion Auscultation

Hair distribution Skin turgor intact,
Hair, Skin, consistent with age, no Nails are smooth,
and Nails lesions or abnormalities capillary refill >2
noted. Nails are convex, seconds.
with no signs of
clubbing or cyanosis.
Normocephalic and No tenderness upon
Skull and atraumatic, facial palpation of facial
symmetry preserved bones.
Face

Pupils equal, round, and

reactive to light and
Eyes accommodation
(PERRLA), extraocular
movements intact,
conjunctivae pink and
moist, no evidence of
ptosis or exophthalmos
Auricles symmetrical, No pain and
no lesions or discharge tenderness
Ears observed, tympanic
membranes pearly gray
with normal landmarks,
hearing within normal
limits.

Nasal mucosa pink and sinuses non-tender

moist, septum midline upon palpation
Nose and
Sinuses

Oral mucosa moist with

no lesions, gums pink
Mouth and and intact, teeth in good
Throat repair, uvula midline,
tonsils within normal
size, no pharyngeal
erythema.
Supple, full range of thyroid non-palpable,
motion, no trachea midline
Neck lymphadenopathy

No masses, asymmetry, No axillary

or nipple discharge lymphadenopathy.
Breast and noted upon inspection.
Axillae

Chest symmetric with Heart sounds

Chest and equal expansion regular rate and
Heart rhythm, no
murmurs, rubs, or
gallops appreciated.

Respirations even and lung fields clear to

Thorax and unlabored auscultation
Lungs bilaterally, no
wheezes, rhonchi,
or crackles.
no masses or Abdomen soft and bowel sounds
organomegaly non-tender, present in all
Abdomen quadrants, no
abdominal bruits
auscultated.

No edema, clubbing, or Pulses palpable and

cyanosis equal bilaterally.
Extremities

Genitalia Did not asses