SAINT LOUIS UNIVERSITY

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

Pulse oximetry: __________

Mental status (e.g. cognitive impairment/
withdrawn/ lethargic):
____________________________________________________
___
Muscle mass/ tone (e.g. normal, flaccid, hypertonic,
hypotonic, spastic, rigid)
____________________________________________

Page 7

Posture (e.g. normal, stooped, curved spine):

____________________________________________________
___
Tremors: ______ Location:
_________________________________

__________________

ROM: Describe:

_______________________________
_______________________________
_______________________________

Strength:

Uses Mobility Aid/s:

_____________________________________
Nursing Diagnosis:
______________________________________
____________________________________________________
____________________________________________________
______
CIRCULATION
Subjective (Reports)
History of/ Treatment for (date):
High blood pressure:
__________________________________
Head injury:
__________________________________________
Stroke:
______________________________________________
Hemoptysis:
__________________________________________
Heart Problem/surgery:
_________________________________
Syncope:
_____________________________________________
Spinal cord injury/ dysreflexia:
____________________________
Palpitations:_____________________________________
______
Bleeding tendencies episodes:
___________________________
Specify:
____________________________________________
Varicosities:
__________________________________________
Heart problems/ Surgery:
________________________________
Thrombophlebitis:
______________________________________
Pain in legs with activity:
_________________________________
Extremities: Numbness:_____ Location:
______________________
Tingling: ____ Location:
__________________________________
Slow healing: sight (describe):
______________________________
____________________________________________________
___

Medication/herbals:
_______________________________________
Objective (Exhibits)
Color:Skin:_____________ Mucous membrane:
Page 1
________________
Lips:_________________ Sclera:
_________________________
Conjunctiva: ________________ Nailbeds:
__________________
Skin moisture (e.g. dry, diaphoretic):
_______________________
Blood pressure: lying:
R: _______ L
___________
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:
_______________________________
_________________________________________________
____

Page 7

Skin lesions:
type:_______________________________________
location:
_____________________________________________
color:__________________________________________
_____
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: __________

Page 7

____________________________________________________
___
size/ girth:
_____________________________________________
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:
Page 2
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:

__________________________
Vitamin/ food supplements:
______________________________
Medication/ herbals:
_____________________________________
Objective (Exhibits)
Current weight: _______ Height: _____________
Body built: ______________BMI: _____________
Skin turgor: ___________________
Mucous membranes (moist/ dry): _____________
Edema: generalized: _____ dependent: _____ feet/
ankles: _____
Periorbital:_________ abdominal/ascites: __________
Breath sounds (location/ adventitious sounds):
____________________________________________________
___
____________________________________________________
___
Condition of teeth/ gums:
________________________________
Dentures (full/partial):
____________________________________
Loose/ absent teeth/ poor dental care:
______________________ sore mouth/ gums:
______________________________________
Appearance of tongue:
___________________________________
mucous membranes:
____________________________________
Abdomen: bowel sounds (quadrant/
location):
_____________________________________________
hernia/ masses:
_______________________________________
Urine S/A or chemstix:
___________________________________
Serum glucose (glucometer):
___________________________
Nursing Diagnosis:
______________________________________
____________________________________________________
____
HYGIENE
Subjective (Reports)
Ability to carry out activities of daily living:
independent/ dependent
(level 1= no
assistance needed to 4= completely dependent):
__________
Mobility: Assistance needed (describe):
____________________
Assistance provided by:
________________________________
Equipment/ prosthetic devices required:
__________________
__________________________________________________
___
Feeding:
______________________________________________
Help with food preparation: ___________
Help with eating utensils: _____________
Hygiene:
Get supplies: ____________
Wash body or body parts: _____________
Can regulate bath water temperature: _______
Get in and out alone: ____________
Preferred time of personal care/ bath:
_____________________
Dressing: ______________
Can select clothing and dress self: ______

Page 7

Needs assistance with (describe):

________________________
Toileting:
______________________________________________
Can get to toilet or commode alone: ______
Needs assistance with (describe):
________________________
__________________________________________________
___
Objective (Exhibits)
General appearance: Manner of dressing:
____________________________________________________
___
Grooming/ Personal habits:
_______________________________
Bath:
__________________________________________________
Shampoo ______ Perineal Care _________
Oral Care _______________
Condition of hair/ scalp:
__________________________________
Body odor: __________
Use of deodorant:
_______________________________________
Presence of vermin (lice, scabies): _____________
Nursing Diagnosis: _________________________
____________________________________________________
____
NEUROSENSORY
Subjective (Reports)
History of brain injury, trauma, stroke (residual
effects):
____________________________________________________
___
Fainting spells/ dizziness:
________________________________
Headaches (location/type/frequency):
______________________
Tingling/ numbness/ weakness (location):
____________________________________________________
___
Seizures:
______________________________________________
History or new onset seizures
Type: _________Frequency: ___________
Aura:
__________
Postictal state:
________________________________________
How controlled:
_______________________________________
Vision:
Loss or changes in vision:
______________________________
Date of last exam:
_____________________________________
Glaucoma: _________
Cataract: _________
Eye Surgery (type/ date):
________________________________
Hearing loss: __________
Sudden or gradual:
______________
Date of last exam:
_____________________________________
Sense of smell (changes):
________________________________
Sense of taste (changes):
________________________________
Epistaxis: ________ Other:
_______________________________
Objective (Exhibits)

Mental status (note duration of

change):______________________
____________________________________________________
__
Oriented/ disoriented: __________ Person:
_______________
Place: _________________
Time:
_________________
Situation:
____________________________________________
Check all that apply:
Alert: _______
Drowsy: ________
Lethargic: ______________
Stuporous: ______ Comatose: ____Cooperative:
_____________
Combative: ___________
Agitated/ restless:
_____________
Follows commands: ____________
Delusions (describe):
____________________________________
____________________________________________________
___
Hallucinations (describe):
_________________________________
____________________________________________________
___
Affect (describe):
________________________________________
Speech:
_______________________________________________
Memory
Recent:
______________________________________________
Remote:
_____________________________________________
Glasgow Coma Scale:
___________________________________
Test
Score
EYE OPENING RESPONSE
SCORE
Spontaneously
4
To speech
3
To pain
2
None
1
MOTOR RESPONSE
Obeys
Localizes
Withdraws
Abnormal flexion
Abnormal extension
None
VERBAL RESPONSE
Oriented
Confused
Inappropriate words
Incomprehensible
None
TOTAL SCORE

6
5
4
3
2
1

Page 3

5
4
3
2
1
15

Cranial Nerves Assessment (describe result)

CN 1 :
________________________________________________
CN 2:
________________________________________________
CN
3:_________________________________________________
CN 4:
________________________________________________
CN 5:
________________________________________________
CN 6:
________________________________________________
CN 7:
________________________________________________

Page 7

CN 8:
________________________________________________
CN 9:
________________________________________________
CN 10:
_______________________________________________
CN 11:
_______________________________________________
CN 12:
_______________________________________________
Mini Mental Status Examination
Folstein Mini Mental Status Examination
Task

Instructions

One point each for

year, season, date,
day of week, and
month

Place
"Where are you?" Ask for
Orientation omitted items.

One point each for

state, county, town,
5
building, and floor or
room

Register 3
Objects

Name three objects slowly

One point for each
and clearly. Ask the patient to item correctly
repeat them.
repeated

Serial
Sevens

Ask the patient to count

backwards from 100 by 7.
Stop after five answers. (Or
ask them to spell "world"
backwards.)

One point for each

correct answer (or
letter)

Recall 3
Objects

Ask the patient to recall the

objects mentioned above.

One point for each

item correctly
remembered

Naming

Point to your watch and ask

the patient "what is this?"
Repeat with a pencil.

One point for each

correct answer

Repeating a Ask the patient to say "no ifs,

Phrase
ands, or buts."

One point if
1
successful on first try

Give the patient a plain piece

of paper and say "Take this
Verbal
paper in your right hand, fold
Commands
it in half, and put it on the
floor."

One point for each

correct action

Show the patient a piece of

Written
paper with "CLOSE YOUR
Commands
EYES" printed on it.

One point if the

patient's eyes close

Writing

Ask the patient to write a

sentence.

Drawing
Ask the patient to copy a pair
of intersecting pentagons onto
a piece of paper.
Scoring

PAIN/ DISCOMFORT
Subjective (Reports)
Location: _____ Quality:
_________________________________
Intensity ( 1,2,3,4,5,6,7,8,9,10 ) ________________

Scoring

Date
"Tell me the date?" Ask for
Orientation omitted items

One point if sentence

has a subject, a verb, 1
and makes sense

One point if the figure

has ten corners and
1
two intersecting lines

A score of 24 or above is considered normal.

Tremors: ________ Paralysis (R/L): _________

Posturing:
_____________________________________________
Wears glasses: _______ Contacts: ___________
Hearing aids: _________
Nursing Diagnosis:
______________________________________
____________________________________________________
___
____________________________________________________
___

30

Deep tendon reflexes (present/ absent): ________

(encircle joint with abonormal reflex, then rate)

Radiation: ____________Frequency: __________

Precipitating factors:
____________________________________
Relieving factors : Pharmacologic:
________________________
Non-pharmacologic (e.g rubbing, rest, herbal)
_____________
__________________________________________________
____
Associated symptoms:
___________________________________
Effect on: Daily activities:
________________________________
Relationships:
________________________________________
Job:
_________________________________________________
Enjoyment of life:
_____________________________________
Objective (Exhibits)
Grimacing: __________ Guarding affected area:
____________
Narrowed focus:
________________________________________
Emotional response (e.g crying, withdrawal, anger):
____________________________________________________
___
Vital sign changes (acute pain): BP: ________
PR: ________
RR:
_________
Nursing Diagnosis:
______________________________________
____________________________________________________
___
____________________________________________________
___
RESPIRATION
Subjective (Reports)
Dyspnea related to: ______________________
Precipitating factors: _________________
Relieving factors: ____________________
Cough (describe): __________________________
sputum (describe character): _________________
Requires suctioning_________
History of (year): bronchitis: ____asthma: _____
emphysema: ____tuberculosis: __
recurrent pneumonia: ______

Page 7

exposure to noxious fumes/ allergens: ___

Infectious agents/ diseases/ poisons/ pesticides:
____________________________________________________
___
Smoker: Yes: ___ No: ___
Type (e.g. menthol) ________ sticks/packs per day:
________
No. of Yrs: ____________
Use of respiratory aids:
__________________________________
Oxygen (type/ frequency):
________________________________
Medications/ herbals:
____________________________________
____________________________________________________
___
____________________________________________________
___
Page 4
Objective (Exhibits)
Respirations
Spontaneous: Rate: __________ Depth:
__________________
Assisted:__________ Parameters:
________________________
__________________________________________________
___
O2 inhalation: _________ Type:
___________________________
Flow Rate:
____________________________________________
Chest excursion (equal/ unequal):
_________________________
Fremitus:
_____________________________________________
Use of accessory muscles:
_______________________________
Nasal flaring: _______________________
Breath sounds:
________________________________________
Egophony:muffled: ___________ clear:
___________________
Skin/ mucous membrane color:
___________________________
clubbing of fingers: _____________
Sputum characteristics: ___________________ Pulse
oximetry: _________
Mentation (e.g. calm, anxious, restless):
____________________________________________________
___
Nursing Diagnosis:
______________________________________
____________________________________________________
___
____________________________________________________
___
SAFETY
Subjective (Reports)
Allergies/ sensitivity (medications, foods,
environment, latex):
____________________________________________________
____________________________________________________
______
____________________________________________________
___
Type of reaction:
________________________________________
____________________________________________________
___

Exposure to infectious diseases (e.g. measles,

influenza, pink eye):
__________________________________________________
____________________________________________________
_
Exposure to pollution, toxins, poisons/ pesticides,
radiation
(describe reactions):
____________________________________
____________________________________________________
____________________________________________________
______
Living conditions (with whom/ location of
residence):
____________________________________________________
___
____________________________________________________
___
____________________________________________________
___
Travelled Places:
________________________________________
____________________________________________________
___
____________________________________________________
___
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify):
______________________________________
Altered/ suppressed immune system (list cause):
____________________________________________________
____________________________________________________
______
____________________________________________________
___
History of STD (date/ type):
______________________________
____________________________________________________
___
test:
__________________________________________________
High risk behaviours:
____________________________________
____________________________________________________
___
Blood transfusion/ number: ___________ Type:
_____________
Date: ______________________________
Reaction (describe):
___________________________________
__________________________________________________
___
Use seat belt regularly: ____Bike helmets: ______
Other safety devices:
____________________________________
Work place safety/ health issues (describe):
____________________________________________________
___
Currently working: ______
Rate working conditions (e.g. safety, noise,
heating, water, ventilation):
____________________________________________
____________________________________________________
___
History of accidental injuries:
_______________________________
____________________________________________________
___

Page 7

Skin problems (e.g. rashes, lesions, moles, breast

lumps, enlarged nodes) describe:
____________________________________________________
____________________________________________________
______
____________________________________________________
___
Delayed healing (describe):
____________________________________________________
____________________________________________________
______
____________________________________________________
___
Cognitive limitations (e.g. disorientation,
confusion):
____________________________________________________
___
Sensory limitations (e.g. impaired vision/ hearing,
detecting hot/cold, taste. Smell,
touch):_______________________________________
____________________________________________________
___
Prostheses: _______Ambulatory devices:
_____________________
____________________________________________________
___
Violence (episodes/ tendencies):
____________________________
____________________________________________________
___
Objective (Exhibits)
Body temperature:__________
Skin integrity (e.g. scars, rashes, ulcerations,
ulcerations, bruises, blisters, burns degree/ %,
drainage) / mark location on diagram:
____________________________________________________
___

STI/ Birth control method:

________________________________
Sexual concerns/ difficulties (e.g. pain, relationship,
role):
____________________________________________________
___
Recent change in frequency/ interest:
____________________________________________________
___
FEMALE: Subjective (Reports)
Menstruation
Age at menarche: __________________
Length of cycle: ____________________
Duration: __________________________
Number of pads/ tampons used/ day: _________
Last menstrual period: _______________
Bleeding between periods: ____________
Reproductive Infertility concerns:
__________________________ Type of therapy
(hormones): ______________________________
Pregnant now: _________
G: _____
P: _____
(TPAL): ________
EDD:
________________________________________________
History of Present Condition: (Start, list and
describe symptoms chronologically from time/day
of onset onwards)
Initial: Wt: ________
Vital signs: BP= _______ HR= ______
RR=
Page 5
________
Temp. _______
Age of Gestation: _______________
Labor
1.Abdominal Status: FU: _____ EFW: ________ AOG:
_________
a) Presence of uterine contraction:
frequency
duration
interval
intensity
b) IE Result:
ti
m
e

(Front)

(Back)

Results of testing (e.g. cultures, immune function,

TB, hepatitis):
____________________________________________________
___
____________________________________________________
___
Nursing Diagnosis:
_____________________________________
____________________________________________________
___
____________________________________________________
___
SEXUALITY (Component of Social Interaction)
Subjective (Reports)
Sexually active: _________

Dilat
n

Effac
et

BO
W
Con
d.

stati
on

discharg
es

Done By

Past Medical History

a.) Includes childhood illnesses (mumps, measles,
german
measles, poliomyelitis, etc)
________________________
______________________________________________
____
______________________________________________
____
b) Any previous health care contacts- Include
diagnostic test
results and date : u/a, cbc, bld. Typing, glucose
screening
test, utz result:
______________________________________
______________________________________________
_____
c) Allergy- include food and drug
hypersensitivity___________
_______________________________________________
____
d) Use of OTC/prescribed drugs
__________________________

Page 7

_______________________________________________
____
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

no. per minute

*Leopolds Maneuver:findings: describe:
LM I:
__________________________________________
_______________________________________________

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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postpartum blues: ________ depression:

_____________
heightened emotional reactions/labile
moods: _________
_____________________________________________
____
Menopause: _____ onset: ____________
Hysterectomy/ Oophorectomy:
____________________________
Problem with: Vaginal lubrication: _____ hot
flushes: ________
Vaginal discharge: ______ others:
________________________
Hormonal therapies:
___________________________________
Osteoporosis medications:
______________________________
Practices BSE: ____ Last mammogram:
____________________
Last Pap smear: _________ Results:
_______________________
Objective (Exhibits)
Genitalia (warts/ lesions): _______
STI test results:
_________________________________________
vaginal bleeding/ discharge: ________
Management: Meds:
prescribed:___________________________
____________________________________________________
___
Nursing Diagnosis:
______________________________________
____________________________________________________
___
____________________________________________________
___
____________________________________________________
___

MALE: Subjective (Reports)

Page 6
Circumcised: ________
Practices self examination: Breast: _________
testicles: ________
Prostate disorder: _________
last prostocopic/ prostate exam: ____________
last PSA date: ______________
Medications/ herbals:
____________________________________
Objective (Exhibits)
Genitalia: Penis (circumcised): _______ warts/
lesions: ______
bleeding/ discharge: _______
Testicles (e.g. lumps): ________ Breast
examination: ________
STI test results:
_________________________________________
____________________________________________________
___
Nursing Diagnosis:
______________________________________
____________________________________________________
___
____________________________________________________
___
SOCIAL INTERACTIONS
Subjective (Reports)

Relationship status: Single: _____ Married: _______

Separated/ Annulled/ Divorced: ________ Widowed:
______
Living with (Specify):
____________________________________
Yrs of Relationship:__________
Perception of relationship:
_______________________________
Concerns/ stresses:
_____________________________________ Role within
family structure: ______________________________
Number/ Age of children: __________________
Perception of relationship with family members:
_____________
____________________________________________________
___
Extended family:
________________________________________ other
support persons: __________________________________
Ethnic/ Cultural affiliations:
_______________________________
Strength of ethnic identity:
_______________________________
Feelings of (describe):
Mistrust:
_____________________________________________
Rejection:
____________________________________________
Unhappiness:
_________________________________________
Loneliness/ Isolation:
__________________________________
Problems related to illness/ condition:
______________________
Problems with communication (e.g. speech,
another language, brain injury):
___________________________________________
Use of speech/ communication
(list)_______________________
____________________________________________________
Is interpreter needed:Yes ______ No ______
Primary language: _________________________
Objective (Exhibits)
Communication/ speech: Clear: ______ Slurred:
_______
Unintelligible: _____ Aphasic: ______
Unusual speech pattern/ impairment: _____
Laryngectomy present: _____
Family interaction (behavioural
pattern)_____________________
____________________________________________________
___
Nursing Diagnosis:
_____________________________________
____________________________________________________
____________________________________________________
______
TEACHING/ LEARNING
Subjective (Reports)
Communication Dominant Language (specify):
____________________________________________________
___
Second language:
_______________________________________
Literate (reading/ writing): ______________
Educational level:
_____________________________________
Learning disabilities (specify):
___________________________ Cognitive limitations:
____________________________________

Page 7

Ethnic Affiliation: __________________________

Health and illness beliefs/practices/ customs:
_______________
____________________________________________________
___
Which family member makes healthcare decisions/
is spokesperson for client:
_________________________________
Presence of Advanced directives: _______ Code
status: _______
Durable medical power of attorney: ___________
Designee:
____________________________________________
Health goals:
___________________________________________
Current health problem: client understanding of
problem:
____________________________________________________
____________________________________________________
______
Special health concerns (e.g. impact of religious/
cultural practices):
_____________________________________________
____________________________________________________
___
Familial risk factors (indicate relationship):
Diabetes: _____________
Thyroid (specify):
____________
Tuberculosis: ____________ Heart disease:
__________
Stroke: __________________ Hypertension:
____________
Cancer: ________________ Kidney disease:
____________
Epilepsy/ seizures: ________
Mental illness/ depression: ___________
others:
_______________________________________________
Vitamins: _________________ Herbals:
____________________
Street drugs: _________
Alcohol (amount/ frequency): ______________
Tobacco: ______ Smokeless tobacco: ______
Expectations of this hospitalization:
____________________________________________________
___
Will admission cause any lifestyle changes
(describe):
____________________________________________________
___
____________________________________________________
___
____________________________________________________
___
Evidence of failure to improve:
____________________________
____________________________________________________
___
Date of last physical exam:
_______________________________
Nursing Diagnosis:
_____________________________________
____________________________________________________
___
____________________________________________________
___

Date information obtained: ___________

Resources available
Persons:
_____________________________________________
financial:
_____________________________________________
Community support:
___________________________________
Groups:
______________________________________________
Areas that may require alteration/ assistance:
Food preparation: _________________
Shopping: _______________________
Transportation: ___________________
Ambulation: ______________________
Medication/ IV therapy: _____________
Treatments: ______________________
Wound care: ______________________
Supplies: _________________________
Homemaker/ maintenance (specify):
____________________________________________________
___
Physical layout of home (specify):
____________________________________________________
___
Referrals (date/ source/ services)
Social services:
_______________________________________
Rehab services:
_______________________________________
Dietary:
______________________________________________
Home care:
___________________________________________
Respiratory/ O2:
_______________________________________
Equipment:
___________________________________________
Supplies:
_____________________________________________
Other:
_______________________________________________

Page 7

DISCHARGE PLAN CONSIDERATIONS

Projected length of stay: ___________________
Anticipated date of discharge:_______________

Page 7

Page 7