NCPRLE 001

Cebu Normal University

College of Nursing
Cebu City
Mission-Vision: Care Using Knowledge and Compassion
Theory-based (Betty Neuman)

ASSESSMENT FORM
Name of Student: _________________________
Name of Clinical Instructor:________________

I.

Area of Assignment: ________________________

Inclusive Dates:_____________________________

CLIENTS PROFILE & CENTRAL CORE

Clients Initials: ______________________Age :_______ Gender:_________Religion:____________

Civil Status: ______________Allergies:____________________________________________________
Diet: _________________________ Height: ____________________Weight: _____________________
Date & time of Admission:_____________________ Mode of Admission: _______________________
Impression/Diagnosis:__________________________________________________________________
Reason for seeking health care: _________________________________________________________
Vital Signs: T:_________ PR:________ RR:________ BP: _________ Pain score:___________________
General Physical
Description:_____________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________
General Behavior
exhibited:______________________________________________________________________________________
______________________________________________________________________________________________
_______________________________________________________________________
Physician in-charge:_________________________________
Nurse-on-Duty: _____________________________________
II.

STRESSORS & REACTIONS TO STRESSORS

A. Clients Complaints Upon Admission
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________
Stressors as perceived by the client and SOs:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________

B. Identification and Reactions to Stressors by person variables/subsystems:

1. Intrapersonal
a. Physiological (Head to Toe)
Past medical history:
Illnesses:____________________________________________________________________________
Surgery:____________________________________________________________________________
History of chronic disease_____________________________________________________________
Immunization History: (specify the number of doses received)
_____ BCG
_____ DPT
_____ OPV
_____ AMV
_____ MMR
_____ HepB
_____ TT
_____ HiB
_____ MMV
_____ Rubella Vaccine _____ Others(specify)
Smoking:
_____ pcks/day
_____ pck/year
Alcoholic Beverages:
______________Type
______________ Amount
______________ Frequency of Use______________ Date of Last Drink
Illicit drugs:
______________Type
______________ Amount
______________ Frequency of Use______________ Date of Last Use
Medication (prescription/OTC)
Medicine

Dose

Frequency

Last Dose

Indication

Allergies:
______________ Foods
______________ Drugs
Perception of health:
_____ good
_____ fair
_____ poor
Dietary Preferences: _________________________________________________________________

Physical Assessment:
Central Nervous System
Level of Consciousness:
_____alert
_____lethargic
_____drowsy
_____Obtunded
_____Stupurous
_____Comatose
Mood (subjective):
_____ pleasant
_____irritable
_____calm
_____happy
_____euphoric
_____ anxious
_____ fearful
_____ others(specify)
Affect (objective):
_____surprise
_____anger
_____sadness
_____joy
_____disgust
_____fear
_____flat
_____blunted
_____full
Orientation Level:
_____person
_____place
_____time
Memory:
_____ recent
_____Intermediate
_____Remote
Pupils: Right
Left
_____size
_____Reaction
_____size
_____Reaction
Reflexes:
_____ grade (describe)
Grasps: Right
Left
_____Strong
_____Weak
_____Strong
_____Weak
Others:
_____Numbness _____Tingling _____Restless
_____ Mannerism
Pain:
None: _____
Provoking/Precipitating factors:________________________________________________
Quality/Location:______________________________________________________________
Radiating or non-radiating:_____________________________________________________
Severity/intensity: _____________________________________________________________
Timing:_______________________________________________________________________
Visual Acuity:
_____Normal
_____glasses
_____ contacts
_____blind (R/L) _____Prosthesis: (artificial eye) R/L
Hearing:

_____Normal
_____impaired (R/L)
_____deaf(R/L)
_____hearing aid _____tinnitus
_____drainage from ears
Touch:
_____Normal

_____abnormal (specify)

Smell:
_____normal
Communication:
_____ Brocas Aphasia
_____ Global Aphasia

_____abnormal
_____ Wernickes Aphasia

Cardiovascular System
Pulse Rate and Characteristics:
_____regular _____irregular
_____strong _____weak
_____ Right Upper Extremity
_____ Left Upper Extremity
_____ Right Lower Extremity
_____ Left Lower Extremity
Heart Sounds:
_____ S1
_____S2
_____Others (specify)
Blood Pressure: _____ standing _____lying
_____sitting
Extremities: Temperature:
Upper Extremities
_____cool _____warm
Lower Extremities
_____cool _____warm
Capillary Refill Time:
_____ second/s
Homan's Sign: _____ Negative _____Positive
Claudication:
_____ Negative _____Positive
Nails:
_____Normal
_____Thickened
_____Clubbing _____Other (specify)

Respiratory System
Chest:
Respirations:

Cough:

_____ symmetrical
_____ asymmetrical (specify)
_____ rate
_____ depth (shallow/deep, abdominal/diaphragmatic)
_____ regular
_____ irregular (specify)
_____ periods of apnea
_____ dyspnea at rest
_____ orthopnea
_____ dyspnea on exertion
_____others(specify)
_____ absent
_____ present (specify)
_____ dry
_____soft
_____ productive
_____ nonproductive
_____ whooping
_____ Sputum:
_____odor
_____color
_____consistency

Breath Sounds:
_____ Normal

_____ Adventitious (specify location)

_____ absent
_____ crackles
_____ rhonchi
_____ friction rub
_____ wheezing

Respiratory devices:
_____ CTT:______________________________________________________________
_____ Tracheostomy: ____________________________________________________
_____ ETT:______________________________________________________________
_____Oxygen Therapy: __________________________________________________

Gastrointestinal System
Prescribed Diet: _________________________________________________________________
Appetite:
_____Normal
_____Abnormal (specify)
Gag Reflex:
_____ Present
_____ Absent
GIT problems: _____ Nausea
_____Vomiting
_____ Dysphagia
_____ Constipation
_____ Diarrhea
_____Incontinence
_____ hemorrhoids
_____ Others (specify)
Feeding Ability: _____ Able
_____ Unable (specify)
Mouth:
_____pink
_____inflammed
_____moist
_____dry
_____lesions/ulcerations
_____ Others(specify)
Oral Prosthesis: _________________________________________________________________
Defecation Pattern:
_____ Consistency
_____ Color

_____ Amount
_____ Frequency
_____symmetry
_____ flat
_____rounded
_____obese
_____Ascites
_____Soft
_____Firm
_____ Tender
_____ Distended
Bowel sounds: _____Hypoactive
_____ Hyperactive
_____Normoactive
_____Absent
Bowel Diversions:
_____ Ostomies (specify)
Abdomen:

Integumentary System
____ color: pallor, ashen, pink, jaundice, cyanotic, ruddy
____ temperature: warm, cool
____dry, moist, clammy, diaphoretic
____Skin integrity: intact, impaired (specify)
____turgor: good, poor
____edema:pitting/non-pitting, dependent, bipedal, periorbital, anasarca
____pruritus
____bruises/lesions
____decubitus ulcer(describe)

Urinary System
Bladder Patterns: _____ color
_____ Amount
_____ Turbidity _____ Frequency
Urinary problems:
_____Dysuria
_____Nocturia
_____Urgency
_____Hematuria
_____Retention _____Burning
_____Hesitancy _____ Incontinence
Elimination Assistive Devices:
_____ catheterization (specify)

Musculoskeletal System
Self-Care Ability: (0=Independent 1=Assistive device 2=Assistance from others 3=Assistance
from person and equipment 4=Dependent/Unable)

Self care
Feeding
Bathing
Dressing
Bed
Mobility

Problems:
Assistive Devices:

Self care
Transferring
Ambulating
Toileting

_____ tremors
_____ atrophy
_____none
_____crutches
_____Walker
_____cane
_____others (specify)

_____ swelling
_____Commode
_____splint/brace _____wheelchair

Gait:
_____normal

_____abnormaI (specify)

_____normal

_____limited (specify)

_____normal
_____Lordosis
_____None
_____None

_____Kyphosis
_____Scoliosis
_____Yes (specify)
_____ Yes (specify)

Range of Motion:
Posture:
Deformities:
Amputation:

Reproductive System
Sexual concerns:_____________________________________________________________________
_____________________________________________________________________________________
Female:
_____LMP
_____GPTPAL Score
_____Menopause (specify)
Family Planning: _____No
_____Yes (type)
Vaginal bleeding:_____No
_____Yes (describe)
History of sexually transmitted disease
_____None
_____Yes(specify)
Last Pap Smear: _________
Male:
Prostate problems
_____No
_____Yes (type)
Penile discharges:
_____No
_____Yes (type

Last prostate exam:_______

Congenital Problems:
_____hypospadia _____epispadia
History of sexually transmitted disease
_____None
_____Yes(specify)

b. Psychological
Overt signs of stress: (crying, wringing of hands, clenched fists)
Coping Strategies:___________________________________________________________________
Impact of Hospitalization/Illness (financial, self-care, role performance):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________
Recent Major loss: ___________________________________________________________________
Living Arrangement:
_____ Alone
_____Nuclear
_____ Extended
Number of Children:
__________________
Occupation:_________________________________________________________________________
Employment Status:
_____employed _____ unemployed
_____unemployed
Social activities:
_____active

_____limited

_____none

c. Spiritual
Religion:

_____Protestant _____Catholic _____Jewish

_____Muslim
_____Buddhist _____others(specify)
Religious Practices/Restrictions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
Concerns related to spiritual or religious customs?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

d. Developmental
Psychosocial tasks:
_______________________________________________________________________
_______________________________________________________________________
Psychosexual task:
_______________________________________________________________________
Cognitive level:
_______________________________________________________________________
Moral Development:
_______________________________________________________________________

2. Interpersonal (between persons) and Extrapersonal (within the community)

a. Socio-cultural
Community participation:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Health cultural beliefs:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Political Affiliations:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Stressors as perceived by the nurse:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________
III.

NURSING DIAGNOSES (in priority)

Classification
Physiological
Psychological
Socio-cultural
Spiritual
Developmental

IV.

Discharge Planning

Clients Initials:
Diagnosis:
Probable Date:
Destination:
Transportation:
Medications

Environment & Exercise

Treatments

Health Education

Observable symptoms

Dietary Prescription

Nursing Problems (at least 5)

Spirituality

_____________________________
Name/Signature of Student
Rating Scale:
5
4
3
2
1

=
=
=
=
=

when the student gives much more than what is expected

when the student gives more than what is expected
when the student gives what is expected
when the student gives less than what is expected
when the student gives much less than what is expected
Summary of Scores
Components
Clients Profile
Clients Complaints
Past Medical History
Central Nervous System
Cardiovascular System
Respiratory System
GIT System
Integumentary System
Urinary System
Musculoskeletal System
Reproductive System
Psychological
Spiritual
Developmental
Socio-Cultural
Nursing Diagnoses
Discharge Planning
TOTAL

__________________________________
Name/ Signature of Clinical Instructor

Highest
Possible
Score
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
85

Actual Score