SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Adolescent-Adult Assessment Tool
(13 y/o and above)
Preliminary Information:
Patients Initial:________________________ Age: ___ Sex
Male
Female Civil Status _______ Occupation______________
Informant: ___________________________ Relationship of Informant to patient: _______________ Religion ____________________
Date of examination: ___________________ Area of assignment____________________ Day of hospitalization __________________
Allergies:
Food: _____________________
Drugs: ___________________
others:
________________________________
VS : T_______ BP____ / _____P______ RR_______

PAIN and DISCOMFORT

O2 Sat______

Weight: _________ Height ___________

Diagnosis:__________________________________________
None
Yes

Presence of Pain/discomfort:

CARE CONCERNS
Pain

Intensity score: ___Location:___________ Radiation:____________ Duration: _______ Onset :_________

Quality:
cramping
dull
burning
sharp
shooting
throbbing
others:_______________

Aggravated by:

movement

others:____________________________________
Relieved by:
eating
quiet environment
others_______________________
Medication/s: _____________________
__________________________
Objective data:
grimacing

______________
Effects of pain:

cold

heat

Ineffective Coping
Others:________

rest

crying

emotions _________

nausea/vomiting

Activity Intolerance

pressure

Non-pharmacologic mngmt:

guarding affected area

others:_________________
Effect of pain to
sleep_______

light

Altered Comfort

withdrawal

appetite___________

activity

Others

_________________________________________________
Diagnosis:_________________________________________________________
HEENT
HEAD:
asymmetrical
unable to support head midline & erect facial color: _______

CARE CONCERNS
Sensory/Perceptu

pain/discomfort
HAIR/SCALP:

al Alteration
Body image

alopecia

baldness

infestations

abnormality:________________________
EYES:
nystagmus
strabismus Lens
sclera:______

Opaque

disturbance
Impaired

Clear __ L __R Color of

Swallowing
Risk For Injury

edema

acuity problems:___________

uses corrective lens:__________

Risk For Aspiration

others:______________________
EARS:
discharges:_____

pain:_____

problems: __L __R

NOSE:
nasal discharge

epistaxis

________________
MOUTH: Lips:
intact

cracked

others:____________________________
Mucus membrane:
moist
dry
others_____________
Dental:
decays ________
others______________
Tonsils:
pain

swelling:_______
occlusion

Others:________

hearing

sinus tenderness:_______ others

lip color______
sores

uses dentures

lesions _________
chewing problem

swelling : size ______

others____________________
NECK:/THROAT:
hoarseness

tinnitus

speech difficulty

bleeding
gingivitis

swallowing difficulties
lump

lymph node

tenderness:____________
Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 1

thyroid enlargement: grade:_____

torticollis

lymph node

enlargement___________________
attached appliances/ devices(IJC,Trach)
status:___________________________________________
Others ________________________________________________________________________________
Medication/s ___________________________________________________________________________
Dx result ______________________________________________________________________________

NEURO

Diagnosis:_________________________________________________________
oriented
disoriented
unresponsive
Sensory state
GCS score: M___ V___ E___ Total=___
Speech:
normal
dysphasia
slurred
blocking

CARE CONCERNS
Seizures

LOC:

poverty of speech
selective mutism

aphasia (

Global)
Cognition: Orientation:

time

Memory:

immediate

Expressive
place

recent

Aspiration
Language

Receptive
person

Depression
Decreased

self
ADLs

remote

Pupils: size: ______ reaction: _______________ deviation: ____________________

Cranial nerves: abn findings______________________________________________
Swallowing:
normal
dysphagia others
___________________________
Behaviors:
calm
restless

Delirium

agitated

withdrawn

others:________________
Seizures:
No

Yes Type: ____________ Duration: ____ Incontinence

______
SCI:level of injury:___

complete

Sensory

__tactile
discrimination
__2 pt
discrimination
__stereognosis
__graphesthesi
a

thought process
Others:_________

incomplete sensory: light touch __ pin

prick___
anal sensation ___ bladder sensation ___ Motor: diapraghm ___ abdominal ___
anal control__ bladder control ___ Elbow: flexors___ extensors ___
fingers: flexors __ abductors__ ; hip flexors ___ ; knee extensors ___ ;
ankle: dorsiflexors ___ plantarflexors __ ; long toe extensors ___
Others:
+brudzinski
+kernigs
headache:________
vertigo
syncope
Others ________________________________________________________________
Medication/s ___________________________________________________________
Dx result _____________________________________________________________
Diagnosis:______________________________________________
MUSCULO-SKELETAL
Mobility:

hemiplegia ____

paresis _______
Muscles:
spastic

quadriplegia

flaccid

tremors

paraplegia ____
tics

CARE CONCERNS
Falls

Motor strength
&DTR

Decreased
ADLs

spasms

Sensory deficit

pain_____________
Muscle mass:

adequate

____________
Assistance Needed:
_________________
Joints: ROM:
full
edema:_________
stiffness:________

emaciated

none

partial

limited:_________
arthritis

Disuse

atrophy _________ others

Syndrome:
Sp:________________
Impaired

full assistive device:

redness :_________
tophi:________

deformities

Hand Grip:
L: ______
R:______
Foot pushes:

Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Physical Mobility
Impaired Bed
Mobility

Page 2

_______________
Amputations:_________________

contractures:_____________

foot drop
Coordination:

slowed

impaired __________

_______________________
Posturing:
kyphosis

lordosis

L:_______
R:_______

Others:_________

Gait:

scoliosis

decorticate

decerebrate
opisthotonus others:__________________________________________
Functional disability:

feeding

toileting

others___________
Supports:
cast:_________

transfer

dressing

sling:________

traction:____________________
Others __________________________________________________________________
Medication/s ______________________________________________________________
Dx result _________________________________________________________________
Diagnosis:_______________________________________________________

RESPIRATORY

Chest shape: ____________

normal

Actual/potential

labored

symmetrical

flaring

___________
Dyspnea:
absent

Cough :

absent

productive

dry

hemoptysis

Perfusion

egophony
paradoxical

Others:________

accessory muscles:
with Activity

central

Infection
Tissue

mouthbreathing

asymmetrical

at Rest

absent

deep
stridor

retractions: _________

orthopnea
Cyanosis :

__

SOB

Lung sounds:
A-Absent
C-Clear (Normal)
D- Decreased
W- Wheeze
Cf - Crackles (fine)
Cc Crackles (coarse)
Lung percussion:
R-resonant
H-hyper resonant
F-flat
Dl -dull

peripheral
harsh

productive

non-

Secretions color/amt: ______________

night sweats
Fremitus:

Airway Clearance

irregular

(sp)________________________________
Depth :
normal
shallow
Expansion:

Posterior:

Gas exchange

pain/discomfort
Rhythm :
regular

Quality :

Anterior:

deformities _____________

CARE CONCERNS

present

absent

Chest Tubes(loc/charac/status):_____________________________________
Oxygen therapy: via________ LPM _______
MechVentilator : type:_______ setting: ____________ mode: ______
Artificial airway:
ET
NT
TT
others_________________________
Medication/s _____________________________________________________
DX Result: ______________________________________________________

CARDIOVASCULAR
chest pain

Diagnosis:___________________________________________________
palpitations

seconds
Apical pulse: rate: ____
PMI:______
Abnormalities:

regular

nails: color_________
irregular

clubbing

Pulse Deficit:

capillary refill:_____
No

Yes

CARE CONCERNS
Activity
intolerance
Impaired comfort
Cardiac

murmurs:______

dynamic precordium

thrills:______

pericardial friction

bruit:________

heaves: _______

others _____________

JVD:Meas._________
Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Output
Tissue
Perfusion
Page 3

Auscultatory areas: Aortic:____ Pulmonic: _____ Tricuspid: ______ Mitral:______

Cardiac Monitor:

yes

no Pace maker:

no

yes Rhythm :

irregular:____________
Pulses : Radial ____L____R Femoral ____L____R Pedal ____L____R
Edema:
pedal L/R
ankle L/R
lower leg L/R
face
Grade: _________
Type of IV line:

central loc. ________

peripheral loc. _________

char:____________
CVP leakage CVP level:____

varicosities __________

_____________
Hema:
bruising:___petechiae ___ ecchymosis

S1

___purpura

BT Type of BT: ________________ :#of units_______

S2

Skin Integrity

regular

Others:
________

non-pitting

pitting

IV infiltration
fistula/shunts: loc

___ hematoma
reactions:_____________________

CBG: _____ q ______ insulin type: ____________ units: ___________

Others:_______________________________________________________________________________
Medication/s :___________________________________________________________________________
Dx results: _____________________________________________________________________________

GIT and
GUT
Diet:

Diagnosis:___________________________________________
_________
oral type: ____________________preference: ______________
100%

75%

50%

25%

Constipation

25%

Diarrhea

0%) others: _____________________________

Dinner: (
100%
75%
50%

25%

Bowel Elimination

0%) others: ____________________________

BMI: _________
TPN:
PPN type: ______________ rate:
Enteral tube type:

yes
NGT

Swallowing
Fluid

0%) others: ____________________________

Lunch: (
100%
75%
50%

___________ tolerated: (

Nutrition
Aspiration

NPO (SINCE):________
Breakfast (

CARE CONCERNS

no)
gastrostomy

jejunostomy

urinary elimination
gastrointestinal motility
Skin Integrity
Others___________

others: _______________________
Insertion date: _________ NG tube suction:
gravity
heartburn

anorexia

nausea

_______________________________
Bowel Sounds:
hyperactive

emesis (describe):

normoactive

hypoactive

absent
Abdomen:

distended

low

rigid

soft

tender

firm

tympanic
dull

ascites

fluid waves

bruit @________
Abdl girth: ____ waist C: ___ hip C: ___ w/h ratio______
BMI:_________
Bowel Activity:

normal regularity : __________

Last BM:___________

Feces: color________ amount/size:___________

characteristics:_________________________________
diarrhea
constipated (# of Days) _____ Aids to
BM:___________________________________
Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 4

melena

hemorrhoids

others_____________________________________________________
Liver:
tenderness
enlargement
esophageal varices
others:____________________________
Kidneys:
flank pain BUN_______________Crea: _________________
Voiding:

continent

incontinent

hesitancy

burning

dysuria

anuria

frequency

urgency

nocturia
hematuria

others:_________________________________________
Urine: characteristics: _______________________output: (7 3): _____311:
_____11 7: _____________
Mass: (Location): _______________ characteristics:
_________________________________________
Dialysis:
hemodialysis:__________
peritoneal:________
Fluid restriction: ______ml/day
Catheter:
Foley
Suprapubic

Condom

Peritoneal

A/V Fistula
Bowel Diversion: (charact/site):
__________________________________________________________
Urinary diversion: (charact/site):
_________________________________________________________
CBI: type of solution _____________________ drainage:
__________________________________
Medications:________________________________________________________________
__________
Screening Methods:
colonoscopy
sigmoidoscopy
barium
Enema

barium sw.

FOBT

Last Date Performed: ________ Results:

___________________________________________________
Lab results:
S/E:______________
UA: _______________
AST/ALT________

Albumin_________

Other Dx
result:___________________________________________________________
_____________
Surgeries:
________________________________________________________________
___________
Medications:______________________________________________________
____________________
Diagnosis____________________________________
REPRODUCTIVE
____________
SYSTEM
FEMALE
Breast (draw abnormalities here)
Menses:
Regular
Irregular;
Amenorrhea:
2ndary
Heavy Flow

primary

CARE
CONCERNS
Sexual Patterns
Knowledge Deficit
Others___________

Menopausal
dysmenorrhea

# of pads used during menstruation:

__________

Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 5

Characteristics of menses/discharge:
__________________
___________________________________
_____________
Breast: symmetry:___
discoloration:___________
tenderrness _________
dimpling:_______________
nodules:_________

undescended
Displaced Meatus
nipple

(Hypospadia/Epispadia) Erectile
Dysfunction:
yes
no

discharge______________
surgically

priapism

absent_____________________________
__
External Genitalia:
Excoriations
Rash
Lesions________
Vesicles

Penile Discharge:
Characteristics:
__________________________
___
Hernia: __umbilical
__inguinal
Phimosis

Inflammation

Discharge
Charac.:____________________________
Screening Methods:
BSE
CBE

MALE:
Scrotum charac.
_____________________
Testicular charac. # of Testes
_______
descended

Mammography

others:_____________________________
_____________
Pap Smear (last pap smear)
_________________
Results:
___________________________________
___

hydrocele

varicocele
others:_____________________
_
Screening Methods:
TSE
DRE

PSA

others______________________
__________

___________________________________
___________
Family Planning Use:

No

Yes

Natural:_______

Artificial: _______ Since when __________

Medications:
________________________________________________________________
_________
DX
results__________________________________________________________
__________________
Surgeries:
_________________________________________________________________
__________
INTEGUMENTARY
Diagnosis___________________________________
CARE CONCERNS
SYSTEM
___________
skin integrity
Temperature ______Turgor:
good
thermoregulatory status
poorSx______________
Risk for infection
Characteristics:
dry
moist
Others:_________
oily
diaphoresis
Color:
flushed

pale

cyanotic

jaundiced

mottled

Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 6

Lesions(type):__________loc/charac._______________________
wounds(type)__________loc/charc_________________________
Ulcers (type)____________ loc/char________________________
infestations ___________________________________________
Others: _________________________________________________
Burns: %______ degree: ________
implants_______________
Medication/s______________________________________________
DX
results__________________________________________________________
_____________
PSYCHOSOCIAL ASSESSMENT
Diagnosis_____________________________________________
Self-Perception/Self-Concept, body image____________________________________________________
Aids and augmentations: _________________________________________________________________
Development: stage, tasks and concerns:(Erickson)_____________________________________________
Expectations and concerns about hospitalization: _____________________________________________
Effects of hospitalization/illness to
self:_____________________
work:
_________________________

family: ________________________________

social

life:___________________________________
Learning needs:________________________________________________________________________
Mood:
depressed
expansive
irritable
euphoric
mood swings
others_________________
Affect:
apathy
flat

blunted

restricted

______________________________
Thought:
content _________________
flow__________________
Perception:
delusion_________
others ________
Motor:
hypoactive

Yes

thought
alteration
perceptual
alteration
Fear
Anxiety
Powerlessness

others

Hopelessness
Sleep pattern
disturbance
Ineffective coping

illusion ____________

others_________ OTHERS:

Impaired

anxiety_________

adjustment
Family needs

ambivalence
Behavior: Appropriate to situation?

self esteem

process ____________________

hallucination __________

hyperactive

labile

CARE CONCERNS
body image

No,

Parenting needs

describe:________________________________________
Sleep:
difficulty falling asleep
not rested after sleep aids to sleep: ___________

Spiritual needs

meds____________
Communication pattern:

Suicide risk

non- verbal

Cultural needs

verbal.

Spec__________________________________________
Stress-Coping pattern? Sources of stress: ___________________ways of coping: ___________________
Availability of support? : source:____________________ adequacy: _______________________________
Role-relationship pattern: (describe role, interaction pattern and concerns)
a. Family: ______________________________________________________________________________
b. Work : _______________________________________________________________________________
c. Community: ___________________________________________________________________________
Sexuality and sexual concerns? Sex Preference:_________
Sexual problems:

Role conflict
Sadness
Depression
Others:_________

_____________________
Aids to sex performance:____________________________
others_____________________________
Social history :
lives alone
lives with:
__________________________________________________
Lifestyle risk:
Smoking, pack years ________
tobacco use: chew ___

smoke ____

Alcohol use; amount:_________how long?__________

betel nut chewing: length of use:______

social drug Type? ____________ Frequency?

____________
Financial concerns(describe)_______________________________________________________________
Housing concerns:
Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 7

_______________________________________________________________________
Legal concerns: _________________________________________________________________________
Cultural/religious practice important to client during hospitalization?_________________________________
Any advance directives?
yes, specify: _____________________
No
Need for more
information
Other concerns: ________________________________________________________________________
I do hereby certify that all information written on this assessment tool are true and correct.
Name of the Student _______________________________ Signature _____________________ Date ____________

Copyright2013 Adolescent-Adult Assessment Tool SLU-SON

Page 8