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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_______ O2 Sat______ Weight: _________ Height ___________
PAIN and DISCOMFORT Diagnosis:__________________________________________ CARE CONCERNS
Presence of Pain/discomfort: None Yes Pain
Intensity score: ___Location:___________ Radiation:____________ Duration: _______ Onset :_________ Altered Comfort
Quality: cramping dull burning sharp shooting throbbing others:_______________ Activity Intolerance
Aggravated by: movement light pressure others:____________________________________ Ineffective Coping
Relieved by: eating quiet environment cold heat rest others_______________________ Others:________
Medication/s: _____________________ Non-pharmacologic mngmt: __________________________
Objective data: grimacing guarding affected area crying withdrawal others:_________________
Effect of pain to sleep_______ emotions _________ appetite___________ activity ______________
Effects of pain: nausea/vomiting Others _________________________________________________
HEENT Diagnosis:_________________________________________________________ CARE CONCERNS
HEAD: asymmetrical unable to support head midline & erect facial color: _______ pain/discomfort Sensory/Perceptual
HAIR/SCALP: alopecia baldness infestations abnormality:________________________ Alteration
EYES: nystagmus strabismus Lens Opaque Clear __ L __R Color of sclera:______ edema Body image
acuity problems:___________ uses corrective lens:__________ others:______________________ disturbance
EARS: discharges:_____ pain:_____ swelling:_______ tinnitus hearing problems: __L __R Impaired Swallowing
NOSE: nasal discharge epistaxis occlusion sinus tenderness:_______ others ________________ Risk For Injury
MOUTH: Lips: intact cracked lip color______ others:____________________________ Risk For Aspiration
Mucus membrane: moist dry sores lesions _________ bleeding others_____________ Others:________
Dental: decays ________ uses dentures chewing problem gingivitis others______________
Tonsils: pain swelling : size ______ swallowing difficulties others____________________
NECK:/THROAT: hoarseness speech difficulty lump lymph node tenderness:____________
thyroid enlargement: grade:_____ torticollis lymph node enlargement___________________
attached appliances/ devices(IJC,Trach) status:___________________________________________
Others ________________________________________________________________________________
Medication/s ___________________________________________________________________________
Dx result ______________________________________________________________________________
NEURO Diagnosis:_________________________________________________________ CARE CONCERNS
LOC: oriented disoriented unresponsive Seizures
GCS score: M___ V___ E___ Total=___ Sensory state Delirium
Speech: normal dysphasia slurred blocking poverty of speech Aspiration
selective mutism aphasia ( Expressive Receptive Global) Language
Cognition: Orientation: time place person self Depression
Memory: immediate recent remote Decreased ADLs
Pupils: size: ______ reaction: _______________ deviation: ____________________ Sensory
Cranial nerves: abn findings______________________________________________ thought process
Swallowing: normal dysphagia others ___________________________ Others:_________
Behaviors: calm restless agitated withdrawn others:________________ __tactile
Seizures: No Yes Type: ____________ Duration: ____ Incontinence ______ discrimination
SCI:level of injury:___ complete incomplete sensory: light touch __ pin prick___ __2 pt
anal sensation ___ bladder sensation ___ Motor: diapraghm ___ abdominal ___ discrimination
anal control__ bladder control ___ Elbow: flexors___ extensors ___ __stereognosis
fingers: flexors __ abductors__ ; hip flexors ___ ; knee extensors ___ ; __graphesthesia
ankle: dorsiflexors ___ plantarflexors __ ; long toe extensors ___
Others: +brudzinski +kernigs headache:________ vertigo syncope
Others ________________________________________________________________
I do hereby certify that all information written on this assessment tool are true and correct.