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HEALTH PERCEPTION
Health Perception:
Statement from patient about how patient
views overall health
Statement from patient about why patient
is hospitalized
Lifestyle:
Lives: alone or specify with whom
Type of home: # of floors
Nursing home
No known residence
Health Maintenance:
Habits: use of alcohol: none, type and
amount per day, week, month
Use of tobacco: none, quit date, pipe,
cigar, cigarettes,; packs per day
Other recreational or OTC drugs; no, yes,
type, usage
Preventative Health Behaviors:
Breast or testicular self examination; yes
or no
Date of last dental examination
Problems that could contribute to falls or
accidents: age 65 or over, confused and
disoriented, hallucinating, history of falls,
recent history of loss of consciousness,
seizure disorder, unsteady on
feet/physical limitations, poor eyesight,
poor hearing, drug or alcohol problem,
postop condition/sedated, language
barrier, attitude (resistant, belligerent,
combative, fearful), postural hypotension
Family history risk factors

HEALTH MANAGEMENT
General appearance:
Race: Caucasian, Black, Hispanic,
Chinese, other
Gender: male, female
Age group: child teenager, young adult
age, middle aged, elderly
Body build: small, average, large
Stature: (Comparison of height and
weight): emaciated, obese, stout, robust,
cachectic, round)
Grooming:
Mental Status: alert/oriented?
Signs of Distress: any grossly abnormal
signs/in acute distressdescribe/in no
acute distress
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Overall health status: healthy for
age/condition? Poor health?

NUTRITIONAL
Previous Dietary Intake:
Diet: regular, no added salt, ADA, soft,
low
cholesterol, high fiber, low residue, clear
liquids, NPO, list other
Vitamins or supplements
Food Preferences
Appetite: % of diet eaten, presence of
nausea or vomiting, decreased taste
sensation.
Nutritional Impairment:
Inability to swallow (dysphagia) none,
solids or liquids, Inability to chew, Inability
to feed self
Weight fluctuations last 6 months: None,
lbs. gained or lost
Dentures: Upper (partial/full), Lower
(partial/full) Usage describe
Allergies: List, NKDA
Skin:
History of Skin/Healing Problems: none,
abnormal healing, rash, dryness, pruritis,
excess perspiration/diaphoresis
Usual Hygiene Practices: Bath/shower,
give frequency.
Skin Care Aides: List
Temperature ranges:

METABOLIC
Height and Weight:
Body Temperature:
Skin:
Color: Light pink to dark pink or light
brown to dark brown, pallor, flushed,
cyanotic, ashen, glossy, jaundiced.
Color Variations: Erythema,
ecchymosis/contusion, petechiae, vitiligo,
pigmented.
Lesions: Macule, patch, papule, plaque,
nodule, tumor, wheal, verruca, nevus,
vesicle, bulla, pustule, furuncle, erosion,
ulcer, fissure, crust, scab, excoriation,
abrasive laceration, INCISIONS.
Texture: Smooth, soft rough thick, scaling
Turgor: Return immediate/return greater
than 3 seconds.
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Temperature and Moisture: Warm, dry,
extremely cool, extremely warm, wet, oily.
Edema: Absent/O, or 1 +, 2 +, 3 +, 4 +.
Hair:
Color: describe
Length: describe
Texture: Fine, coarse, pliant, brittle, dull,
shiny, lustrous, glossy, resilient, dry, oily.
Distribution: thick, thin, evenly
distributed, sparse, alopecia, hirsutism
Scalp:
Oily, dry, scaling, dandruff, lumps or
lesions (note location, size, tenderness,
inflammation or drainage
Oral Mucous Membranes:
Color: Pink, pale, cyanotic, reddened.
Consistency: Smooth, moist, dry,
bleeding, ulcers, presence of white
patches, describe lesions.
Gums: Describe color, texture clearly
defined margins receding or shrunken,
firm, spongy, edematous, any
tenderness?
Oral Mucous Membranes:
Color: Pink, pale, cyanotic, reddened.
Consistency: Smooth, moist, dry,
bleeding, ulcers, presence of white
patches, describe lesions.
Gums: Describe color, texture clearly
defined margins receding or shrunken,
firm, spongy, edematous, any
tenderness?
Nails:
Color: Pink, pale, cyanotic, splinter
hemorrhages
Shape: Beaus lines, clubbing, spooned.
Texture: Smooth, hard, jagged, soft
Nail bed: Pink, pale, inflamed.
Capillary Refill: 1-2 seconds, 3 seconds,
or longer.
Decubitus Risk Factor: Calculate; give
score.
See Braden Scale
Teeth:
Any teeth missing upper? Lower?
Condition: loose or broken; smooth or
jagged edges; crooked or straight;
protruding; dental caries; sores.
Color: pearly white and shiny, darkened,
brown discoloration
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Dietary Intake: regular, no added salt,
ADA, soft, low cholesterol, high fiber, low
residue, clear liquids. NPO, list other
Amount eaten: 50% or less = poor,
50-75% = fair, 75-100% = good
Fluid Intake during care:
Oral: give in ccs
IV: give in ccs

ELIMINATION
Previous Urinary Pattern:
Frequency of voiding: every __ hours or
___ times/day
Problems: Presence of incontinence,
dysuria, hematuria, nocturia, urgency,
hesitancy
Previous Bowel Pattern: Number of
BMs/day, constipation, diarrhea,
incontinence, presence of ostomy
Use of laxatives, enemas, suppositories
Last bowel movement
Presence of heavy
perspiration/diaphoresis
Urinary
Mode: indwelling catheter, external
catheter, incontinence briefs, ileal
conduit, toilet, urinal, bedpan
Color: pale to dark yellow, straw colored,
amber
Characteristics: clear, cloudy, hazy,
sediment, aromatic
Bowel/stool
Bowel Sounds: audible, hyperactive,
hypoactive, inaudible, present, active, not
present equally in all quadrants
Abdominal appearance:
Contour: rounded flat, distended, round,
scaphoid, enlarged, protruding, hard,
rigid, relaxed, taut, pendulous,
tympanites
Symmetry: symmetrical, asymmetrical
Surface motion: no movement, bounding
peristalsis, bounding pulsations
Feces:
Color: dark brown, med. Brown, mustard
yellow green, dark red/bright red, black,
tarry, clay-colored
Amount: small, med, large
Consistency: soft semisolid, formed, hard,
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loose
Characteristics: mucoid, foul-smelling,
aromatic, pencil-like, bulky, pasty
Drainage:
Amount: give in ccs, describe size on
dressing
Color: pink, red, green, brown, white,
yellow
Odor: aromatic, unique, strong
Consistency: thick, mucoid, watery, thin,
frothy, tenacious
Characteristics: purulent, suppurative,
mucopurulent, sanguineous, blood tinged,
serosanguineous, serous

ACTIVITY
Previous pattern of activity:
eating/drinking, bathing,
dressing/grooming, toileting, bed mobility,
transferring, ambulating, stair climbing,
shopping, cooking, home maintenance
History of tolerance limitations: pain,
stiffness, dyspnea, fatigue, frequent
pauses in activity to rest, dizziness
Mobility aids: crutches, bedside
commode, walker, cane, splint/brace,
wheelchair, other
Limitations in ability: missing limbs,
paralysis deformities, casts
Vital sign ranges: either since
hospitalization or verbal from patient
Use of diversional activities

EXERCISE
Present pattern of activity:
eating/drinking, bathing,
dressing/grooming, toileting, bed mobility,
transferring, ambulating, stair climbing,
shopping, cooking, home maintenance.
Rate as independent, use of assistive
device, assistance from others, assistance
from person and equipment,
dependent/unable
Musculoskeletal:
Posture: relaxed, shoulders back, tense,
rigid, slumped, asymmetrical posture,
kyphosis, lordosis
Muscle tone: slight resistance, spasticity,
rigidity, flaccidity
Muscle strength: rate all major muscle
groups according to the following scale:
0= No muscular contraction
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1= Barely flicker of contraction
2 = Active movements with gravity
removed
3 = Active movement against gravity
4 = Active movement against gravity
and some resistance
5 = Active movement against full
resistance with no fatigue
Gait: spastic, hemiparesis, scissors,
steppage, sensory ataxia, cerebellar
ataxia, Parkinsonism
Balance: steady, unsteady
Range of motion: unlimited, full, limited
with crepitation or pain, immobile,
decreased, restricted
Weight bearing: give in percentages,
ability to stand on left/right heels/toes,
weakness, inability to use either
extremity
Cardiorespiratory:
Lungs:
Breath sounds: clear, crackles, rhonchi,
wheeze
Rate: apneic, eupneic, tachypneic,
bradypneic
Rhythm: regular, irregular
Depth: deep, shallow
Cough: continuous, persistent, frequent,
productive, nonproductive, spasmodic,
paroxysmal, tight, loose, deep, dry,
hacking, harsh, painful, rasping,
exhaustive
Use of O2: flow rate and method of
delivery mask, nasal cannula
Heart:
Rate: give in numerical value,
tachycardic, bradycardic
Rhythm: regular, irregular, regularly
irregular, irregularly irregular
Peripheral Vascular:
BP
Peripheral Pulses: strong, equal,
bounding, thready, imperceptible, weak
asymmetrical, absent, 1+, 2+, 3+, 4+
Sensation: nontender, can identify light
and deep touch, paresthesia, tenderness,
pain, tingling, burning, stinging, prickling,
numb
Motor: Hand grasps and foot movement:
equal, strong, weakness, paralysis
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Present tolerance for activity: pain,
stiffness, dyspnea, fatigue, frequent
pauses in activity to rest, dizziness

COMFORT/SLEEP
Sleep patterns: Bedtime, hours slept,
Routine: AM nap, PM nap, work night
shifts, variable work shifts
Sleep aides used: medication, food,
rituals
Position of comfort
Problems: none, early waking, insomnia,
nightmares

REST
Observe appearance: pale
Observe behavior: yawning
Problems: none, early waking, insomnia,
nightmares

COGNITIVE
Knowledge Level/Educational level
achieved:
Primary language spoken
Ability to express self verbally Words or
types of expressions used
Ability to follow verbal/written
instructions: Yes; if no, explain
Developmental Level: based on
age/education- is this consistent or
inconsistent?
Insight: describe; give patient statement
(how did you come up with development
level?
Past History of cognitive/perceptual illness
Past History of sensory perception:
Heat
Hearing
Cold
Sight
Taste
Touch
Smell
Vertigo
Pain Assessment: location, intensity,
duration, quality, predisposing factors
Grade on 1-10 scale
Pain Assessment: location, intensity,
duration, quality, predisposing factors
Grade on 1-10 scale

PERCEPTUAL
Memory
Long term: intact, impaired, GIVE
EXAMPLE
Short term: intact, impaired, GIVE
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EXAMPLE
Speech:
Paralanguage: qualities of speechpitch, intonation, rate of speaking, voice
volume, words that are stressed or
accented.
Articulation: articulate, not articulate:
DESCRIBE
Sequencing: logical, illogical:
DESCRIBE
Appropriateness of content:
appropriate, inappropriate
Neurological:
Orientation: person, place, time
Pupil reaction: sluggish, brisk, PERRLA
Grasp Strength:
Level of consciousness: comatose,
unresponsive to verbal or painful stimuli,
semiconscious, stuporous, drowsy,
lethargic, alert, responsive
Perceptual Cognitive:
Hallucination: absent, present
Delusions: absent, present
Attention span: intact, not intact:
DESCRIBE
Sensory:
Visual Impairment: absent, present,
glasses, contacts, prosthesis
Auditory Impairment: absent
Auditory aide: absent
Other sensory impairments: absent
Auditory Impairment: absent
Auditory aide: absent
Other sensory impairments: absent,
present: describe

SELF PERCEPTION
Developmental stage of life: give
supporting data. ERICKSONS
Ability to accomplish age level tasks:
describe present health goals
Ask the patient: How would you describe
yourself? What do you consider to be your
strengths? What do you consider to be
your weaknesses?
Patients perception of ability to achieve
goals.
Are the goals and responses age related?
Body Image
Mood: patient describes how he is
feeling. Also listen for: expressions of
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positive outlook, expressions of negative
outlook.

SELF CONCEPT
Posture
Eye contact: present, absent, DESCRIBE
Facial expression (affect): animated, sad,
fixed, DESCRIBE
Grooming: Hair groomed: yes, no
Hygiene: good, poor,
describe
Makeup: present, absent
Shaven: yes, no
Dress: neat, not neat:
describe
Affect: outward expressions of feelings or
emotions
Describe: facial expressions (animated,
flat, sad, fixed, smiling, frowning, etc.)
Attitude: DESCRIBE
Expressed feelings about self:
Self affirmation comments: present,
absent, describe
Self derogatory comments: present
Appropriateness of behavior: appropriate

ROLE
Patterns of relating to others
Identification of own role
Response to authority, peers,
subordinates
Age, marital status, occupation
Perceptions of responsibilities in life,
situations at home, work and in the
community. Any role changes caused by
illness?

RELATIONSHIP
Observe patients interactions with others
Verbal, nonverbal communication:
DESCRIBE
Does patient have visitors?

COPING STRESS
Coping patterns, use of counseling, usual
methods of problem solving
Support system
Recent loss or change in life situation
Presence of stress-related disorders

TOLERANCE
Behavior patterns:
Abusive to self or others
Nervous, relaxed, controlled, agitated,
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mood swings; describe
Appearance
Affect
Ability to reason and make sound
decisions: Able, unable, describe

SEXUALITY
Number of living Children, abortions,
miscarriages, stillbirths
Sexual self-feelings toward sex, role, selfconcept
Effect of illness or impairment to sexuality
Present sexual activity
Use of birth control
Age of onset of menses; menopause
Last pap smear (date)
Mammogram (date)
Prostate exam (date)

REPRODUCTIVE
Breasts: round, pendulous, sagging;
equal, pink with/without presence of
striae
Areola: pink to dark brown, round, oval,
evened, presence of discharge
Genitalia: presence and distribution of
public hair, sexually mature, visible
lesions, odor, drainage
Inappropriate sexual behavior: Describe
if observed

VALUE
Health/illness beliefs
Spiritual, cultural, ethnic heritage and
pattern of participation in
Concern with meaning of life/death:
present, absent, describe
Concern with meaning of suffering:
present, absent, describe
Anger towards God/religion: present,
absent, describe

BELIEF
Symbols of Faith: present, absent,
describe
Current religious/cultural ties: present,
absent, describe (praying, meditation,
reading religious artifacts, wearing
religious jewelry)
Visits from clergy
Behavioral patterns of despair: Describe
any observed (withdrawal, anxiety, grief,
apathy, anger, guilt)
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