RLE FORM 001

Cebu Normal University

College of Nursing
Cebu City

NURSING ADMISSION AND ASSESSMENT

Name of Student: Clinical Assignment:

Name of Clinical Instructor: Inclusive Dates:

A. General Admission Information

Name of Patient: Age: Sex:

Date: Time: Mode: Allergies:

TPR: BP: HT: WT: Diet:

Sleeping Habits: CBC: Yes No Urinalysis: Yes No

Property: Glasses Contact Lenses Dentures

Prosthesis Ring Watch Money
Other

Valuable to Business Office

Physical Appearance:

Behavior Exhibited:

Content of Conversation:

_____________________________
Physician In-charge

B. Admission Interview

[1]
1. Patient’s perception of reason for admission:

2. Patient’s symptoms as he/she sees them:

3. Problems in daily living created by symptoms (as patient views them)

4. Past Medical History (especially as it relates to P.I.)

a. Medical

b. Surgical

c. Allergies

d. Medication

e. Traumatic Injuries

f. Orthopedic

g. Other (psychiatric, etc.)

5. Habits:
a. Smoking Alcohol Drugs

b. Eating

c. Social Activity Physical Exercise

d. Rest/Sleeping

e. Sexual

f. Elimination

6. Social Economic History:

a. Native Language

b. Education

c. Occupation

[2]
 d. Financial Status (what is the impact of current hospitalization)

e. Civil Status: Married Single Divorced Widow

f. Living Situation: Lives alone

Lives with others (specify)

7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify)

8. Primary Physician’s Admitting Diagnosis (indicate P = Probable and C= Confirmed)

C. Nursing Review of Systems (circle the appropriate symptoms)

1. HEENT: Headaches Hearing loss Visions Diplopia
Eye pain Eye infection Blurring Epistaxis
Sinus pain Facial pain Bleeding gums Dentures
Sore throat Nasal-tracheal pain Other

2. CARDIO-RESPIRATORY: Chest pain (site)

Chest pain with exertion Dyspnea on exertion

Nocturnal dyspnea Edema Hypertension Palpitation
Known murmur Cough Sputum Hemoptysis
Pleuritic pain Diaphoresis
Last X-ray EKG

3. GASTRO-INTESTINAL:

Thirst Nausea Vomiting Hematemesis

Heartburn Difficulty Swallowing Flatulence Constipation
Abdominal pain Jaundice Diarrhea Tarry stool
Hemorrhoids Hernia Other:

4. GENITO-URINARY:

Dysuria Polyuria Frequency Urgency

Nocturia Burning Hematuria Stones

a. Female Genital Tract – Menstrual History: Age of onset

[3]
 Frequency Regularity Duration

Date last period Post menopausal bleeding

Age Symptoms

b. G P Ab

c. Male Genital Tract: Penile discharges Lesions

Pain Testicular swelling
Other

Last Serology Test

5. MUSCULO-SKELETAL:

Muscle pain Extremity pain Joint pain Back pain

Joint swelling Neck pain Stiffness Limited motion
Redness Sprains Deformity
Other

X-rays

6. NERVOUS:

Convulsions Syncope Dizziness Vertigo

Tremor Speech difficulty Limp paralysis Paresthesia
Muscle atrophy
EEG

Other

7. ENDOCRINE:

Goiter Tremor Heat or Cold intolerance

Exopthalmos Voice change Polydipsia
Change in body contour Infedility Other

8. EMOTIONAL:

Anxiety Depression Fear

Anger Frustration Other (specify)

Notes:

D. Nursing Observation
1. HEENT
a. Symmetry

b. Eyes and Pupils

c. Ears

d. Mouth and Throat

e. Lymph nodes

2. RESPIRATORY

[4]
 a. Depth and Rate

b. Breath sounds

c. Chest expansion

3. CARDIO-VASCULAR
a. Blood Pressure (R) (L) Lying Standing

b. Apical pulse rate and regularity

c. Pedal pulses rate per minute (R) (L)

d. Neck vein distention

4. CHEST
a. Anterior chest

b. Posterior chest

c. Breasts

1. Breasts and Axillae

2. Anterior Thorax

3. Posterior Thorax

5. GASTRO-INTESTINAL
a. Bowel Sounds

b. Tenderness or rigidity

6. URINARY
a. Bladder

7. SKELETAL
a. Joints

b. Range of motion

8. NEURO
a. Motor Function
1. Facial

2. Extremities

b. Sensory Function (equal or not equal)

c. Equilibrium
1. Balance

2. Finger to nose

[5]
 d. Reflexes ( equal or not equal)
1. Knees Arms

9. CRANIAL NERVE FUNCTION

a. Olfactory nerve: (sensory)
1. Sense of smell (coffee, vailla, etc.)
1.1Anosmia

1.2Hyperosmia

b. Optic nerve: (sensory)

1. Sense of vision (snellen’s chart, newspaper)
1.1Myopia

1.2Hyperopia

c. Oculomotor: (motor)
1. Extra-ocular movements/Pupil reaction to light
1.1Right eye 1.2 Left eye

d. Trochlear: (motor)
1. Assess direction of gaze, upward and downward movement of eyeball

e. Trigeminal nerve: (Sensory and motor)

1. Presence of corneal reflexes

1.1 Right eye 1.2 Left eye

2. Ability to clench teeth

f. Abducens: (motor)
1. Assess direction of gaze, lateral movements of the eyeballs
1.1 Right eye 1.2 Left eye

g. Facial: (Sensory and motor)

1. Sense of taste: Using back of tongue
1.1 Salty 1.2 Sweet

2. Facial expression
2.1 Smile 2.2 Puff out cheeks

2.3 Frown 2.4 Raise lower eyebrows

h. Auditory nerve: (motor)

1. Sense of hearing
1.1 Right ear 1.2 Left ear

i. Glossopharyngeal: (Sensory and motor)

1. Sense of taste: Using back of tongue

[6]
 1.1 Salty 1.2 Sweet

2. Ability to swallow (Use tongue blade to elicit gag reflex)

j. Vagus: (Sensory and motor)

1. Hoarseness of voice

2. Sensation of pharynx

Let patient say “ah” and observe(movement of palate and pharynx)

k. Spinal accessory: (motor)
1. Movement of:
1.1 Head 1.2 Shoulder

l. Hypoglossal: (motor)
1. Able to stick tongue to midline

10. EMOTIONAL
a. Communication

b. Mood/Effect

c. Behavior

E. Knowledge of Illness
1. Learning Limitations

2. Learning needs

F. Nursing Impressions

G. Nursing Problems (in priority)

1.

2.

3.

4.

[7]
 5.

H. Discharge Planning
1. Probable Date

2. Destination

3. Transportation

4. Agencies and Equipment involved

5. Diet

6. Medications

7. Persons responsible for patient

8. Family conference

9. Anticipated problems

10.Home visit

Rating Scale:

5 = gives much more than what is expected

4 = gives more than what is expected
3 = gives what is expected
2 = gives less than what is expected
1 = gives much less than what is expected

______________________________ ___________________________________
Signature of Student Signature of Clinical
Instructor

[8]