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CHINESE GENERAL HOSPITAL COLLEGE OF NURSING

ADULT ASSESSMENT TOOL GUIDE

Student: Yr. / Sec.: Area:

Name: Date Admission: Unit/Bed No.

Age: Sex: Civil Status: Religion:

Diagnose/Impression:

Operation (if any):

Chief Complaint:

History of Present Illness:

I GENERAL PHYSICAL ASSESSMENT & CRANIAL NERVE TESTING

Vital Signs: T: R: BP: Height: Weight:

Physical Appearance / Posture / Body Movements / Hygiene / Nutritional Status:

Level of Consciousness / Facial expression / Mood and Affect / Speech / Gait:

SKIN:
- ( ) Birthmarks , ( ) Lesions, ( ) Thickness, ( ) Turgor, ( ) Edema,
( ) Moister, ( ) Vacularity
- Color –

HEAD:
- ( ) Lesions, ( ) Lice infestation, ( ) Cranial Nerve V, ( ) Cranial Nerve VII,
( ) Head Control
- Shape –
- Hair Color –

NECK & SHOULDERS


- ( ) Range of Motion, ( ) Lumps, ( ) Symmetry, ( ) Cranial Nerve XI

EYES:
- ( ) Symmetry, ( ) PERRLA, ( ) Cranial Nerve II, ( ) Cranial Nerve III,
( ) Cranial, Nerve IV, ( ) Cranial Nerve VI
- Conjunctiva –
- Sclera –

EARS:
- ( ) Alignment, ( ) Hearing Acuity, ( ) Cranial Nerve VIII, ( ) Presence of
Foreign Body, ( ) Odor or Discharge
- Position –

NOSE:
- ( ) Alignment, ( ) Symmetry, ( ) Patency, ( ) Presency of Odor, ( ) Discharge,
( ) Lesions, ( ) Flaring of Alae Nasi, ( ) Cranial Nerve I

MOUTH & THROAT:


- ( ) Presence of Lesions, ( ) Inflammation, ( ) Fissures, ( ) Sores, ( ) Odor, ( )
Cranial Nerve IX, ( ) Cranial Nerve X, ( ) Cranial Nerve XII
- Teeth –
- Gums –
CHEST
- ( ) Retraction, ( ) Lung Field, ( ) Symmetry of Chest Expansion, ( ) Tenderness,
( ) Heaves and Thrills over Precordium

ABDOMEN:
- ( ) Contour, ( ) Palpable Organs, ( ) Tenderness,

GENATALIA & ANUS:


- ( ) Skin Integrity, ( ) Presence of Lesions, ( ) Rashes, ( ) Discharge

EXTREMITIES:
- ( ) Range of Motion, ( ) Symmetry of Length and Size, ( ) Muscle Tone,
( ) Edema, ( ) Strength
- Number of Fingers –
- Number of Toes –
- Color –

SPINE:
- ( ) Curvature, ( ) Mobility, ( ) Presence of Defects

II. SIGNIFICANT HEALTH PATTERNS

A Sleep
Hours:
Bedtime Rituals:

B. Activity & Exercise

C. Nutrition
Food Preferences:
Amount:
Dietary Restrictions:

D. Elimination
- Bowel Pattern:
Color:
Frequency:
Consistency:
Odor:
- Urinary Pattern:
Color:
Frequency:
Consistency:
Odor:
E. Work
Type: Hazards:

F. Rest & Recreation

G. Others:

III. WORK UPS


A. Diagnostic Studies

B. Laboratory Examinations:

C. Others

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