TỔNG ÔN TẬP THI VÀO LỚP 10 MÔN TIẾNG ANH NĂM HỌC 2023 - 2024 CÓ ĐÁP ÁN (NGỮ Â...
Assessment tool
1. Cagayan De Oro City
COLLEGE OF NURSING
ASSESSMENT FORM
GENERAL INFORMATION
Patient’s Name: Age: Sex:
Address: Status: Religion:
Educational Attainment: Occupation:
Nationality: Income:
Name of Spouse/Guardian: Contact Number:
Date of Admission (MM/DD/YY): Time of Admission:
Baseline Vital signs: BP: T: PR: RR:
Weight upon admission (in Kg): Height (in ft & in):
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
HOSPITALIZATION HISTORY
ALLERGIES: Yes No (If yes, specify below)
Food: Medications: Others:
BLOOD TRANSFUSION HISTORY: Yes No (If yes, indicate below.) BLOOD TYPE:
DATE OF TRANSFUSION INDICATION REACTION
MEDICATION HISTORY (Previously taken, maintenance, current, etc.)
DRUG NAME DATE TAKEN SCHEDULE INDICATIONS
LABORATORY EXAMS/IV FLUIDS
Date ordered
(mm/dd/yy)
Diagnostic / Laboratory
exams
Date done
(mm/dd/yy)
Date ordered
(mm/dd/yy)
IV fluids/blood Date discontinued
(mm/dd/yy)
Have you been taking your medication(s) as prescribed? Yes No
DATE OF ADMISSION NAME OF INSTITUTION DIAGNOSIS/INDICATION
2. A. NUTRITION AND METABOLIC PATTERN
Special diet: Yes (specify) No
Supplements: Yes (specify) No
Nutritional state:
Well-nourished poorly nourished Obesity Cachexia
Mouth:
Lips Mucosa Tongue Teeth
Pinkish Pinkish Midline Complete
Pallor Pallor Atrophy Caries _____
Cyanosis Cyanosis Fasciculation Missing teeth_____
Lesions R/L deviation Dentures _____
Dryness/cracks
Gums
Pinkish _____ Pallor _____ Bleeding _____ Tenderness _____
Pharynx:
Uvula Mucosa Tonsils Posterior Pharynx
Midline _____ Pinkish _____ not inflamed _____ Inflammation _____
R/L deviation _____ Pallor _____ R/L Deviation _____
Reddish _____ R/L Exudates _____
Neck:
Trachea Thyroids Others:
Midline _____ R/L deviation _____ Non-palpable _____ Neck enlargement _____
Lymphadenopathy _____ Tenderness _____ Enlarged _____ Normal ROM _____
Cervical Lymph Nodes _____ Neck rigidity _____
Skin:
General Color Texture Temperature Moisture
Pinkish _____ Smooth _____ Warm _____ Dry _____
Cyanotic _____ Rough _____ Cool _____ Moist/Clammy _____
Pallor _____ Others: Others: Oily _____
Flushed _____ _______________ ________________
Jaundiced _____
Mottled _____
Dusky _____
Others
Petechiae _____ Ecchymosis _____ Hematoma _____ Lesions/Rashes _____
Edema: Pitting _____ (If pitting, specify below) Non-pitting _____
Pedal: R _____ L _____ Bipedal _____ Grading: _____
Wounds/drains/dressings: ____________________________________________________________________________________________
Intravenous fluids: __________________________________________________________________________________________________
B. ELIMINATION PATTERN
Usual bowel pattern (Describe character of stool, frequency, discomforts)
_________________________________________________________________________________________________________________
_
Date of Last BM (mm/dd/yy): ______________________________ Melena _____ Hematochezia _____
Are there any problems with hemorrhoids/incontinence? Yes _____ No _____
Use of anything to manage bowels (e.g. laxatives, enema, suppositories, “home remedies”, anti-diarrheal)
_________________________________________________________________________________________________________________
_
Abdomen
General Configuration Percussion Palpation
Superficial Veins _____ Symmetrical _____ Tympanitic _____ Muscle guarding ____
Striae _____ Asymmetrical _____ Hypertympanitic _____ direct tenderness ____
Scars/Lesions _____ Flat _____ Fluid wave _____ Rebound tenderness ____
Globular _____ shifting dullness _____ Bladder distention ____
Protuberant _____ Dullness at: Organomegaly:
Scaphoid _____ __________________ Liver _____ Spleen ____
Masses at:
_____________________
3. Usual urinary pattern (Describe frequency, character, amount, problem in control, etc.)
_________________________________________________________________________________________________________________
_
Dysuria _____ Hematuria _____ Nocturia _____ Retention _____
Flank pain _____ Polyuria _____ Oliguria _____ Anuria _____
Excess perspiration/nocturnal sweats: ______________________________________________
C. ACTIVITY – EXERCISE PATTERN
Cardiovascular Status
Chest pain/radiation _____ Jugular vein distention _____ Dyspnea on exertion _____
Orthopnea _____ Palpitation _____ Paroxysmal nocturnal dyspnea _____
Precordial area Heart Sounds Peripheral pulses
Flat _____ Distinct _____ Symmetrical _____
Bulging _____ Regular _____ Regular _____
Tenderness _____ Faint _____ Faint _____
Heave _____ Irregular _____ Strong _____
Thrill _____ Others: Bounding _____
Apical rate and rhythm: S3 _____ S4 _____
_____________________ Preicardial rub _____
Capillary Refill __________________________
Presence of Pacemaker/A-V Shunt/Hemodynamic monitoring ___________________________________
Respiratory Status:
Breathing Pattern Shape of chest Lung Expansion
Regular _____ Irregular _____ Normal APL ratio _____ resonant _____
Eupnea _____ Hyperpnea _____ Barrel chest _____ Dullness at:
Tachypnea _____ Bradypnea _____ Funnel _____ ______________
Dyspnea _____ Rest _____ Pigeon _____ Hyperresonant at:
Exertion _____ ______________
Use of accessory muscles _____
ICS retractions/bulging _____
Pain on respiration _____
Vocal/Tactile Fremitus Percussion Breath Sounds
Symmetrical _____ Resonant _____ Rhonchi _____
Decreased/increased at: Dullness at: Bronchovesicular at ________________
____________________ ______________ Rales/crackles at ________________
Hyperresonant at: Bronchial at ________________
______________ Pleural Friction Rub ________________
Wheezes at ________________
Cough
Productive _____ Non-productive _____
Sputum
Color _________ Amount __________ Consistency __________
O2 supplement/ventilatory assistance __________________________________________________
Respiratory Tubes (e.g. ET, trach, chest tube/describe secretions and/or drainage)
___________________________________________________________________________
Activities of Daily Living/Mobility Status
Use the Activity Level Code below to assess ADL & Mobility Status
0- Total Independence
1- Assist with Device
2- Assist with Person
3- Assist with Device Person
4- Total Dependence
ADL Status Mobility Status
Feeding _____ Meal Preparation _____ Bed Mobility _____
Bathing _____ Cleaning _____ Chair/Toilet Transfer _____
Dressing _____ Laundry _____ Ambulation _____
Grooming _____ Toileting _____ R.O.M. _____
Reasons for ADL/Mobility Limitation ____________________________________________________________________________
Device used for assistance __________________________________________________________________________
Exercise pattern (describe type, regularity) ___________________________________________________________
5. Nose
Alar flaring _____ Shallow nasolabial fold _____
Septum Mucosa Discharge Patency
Midline _____ Pinkish _____ Serous ____ Both patent _____
Deviated _____ Pale _____ Mucoid ____ R obstruction _____
Perforated _____ Reddish ______ purulent ____ L obstruction _____
Bloody ____ Masses/lesions (describe):
____________________
Gross smell Sinuses
Normal/Symmetrical _____ Tenderness _____
R olfactory deficiency _____ Maxillary _____
L olfactory deficiency _____ Frontal _____
Cognition
Primary language _________________________________________ Speech difficulties ____________________
Are there any learning difficulties? Yes ______ No _____
Are there any changes in memory lately? Yes _____ No _____
Pain
No problem __________ Problem __________
Location ____________________ Type ____________________
Intensity ____________________ Onset ____________________
Duration ____________________
Methods of pain management ________________________________________________________________
E. SLEEP – REST PATTERN
Usual sleep/rest pattern ______________________________________________________________________
Adequate: Yes _____ No _____
Factors affecting sleep/rest _____________________________________________________________________
Methods to promote sleep _____________________________________________________________________
F. SELF – PERCEPTION AND SELF – CONCEPT PATTERN
How do you describe yourself? _______________________________________________________________________
Are there any ways the patient feel differently about his/herself since he/she has been ill/hospitalized? ______________
________________________________________________________________________________________________
Description of nonverbal behaviors: __________________________________________________________________
G. SEXUALITY – REPRODUCTIVE PATTERNS
Are there any changes/problems with sexual relations? _____________________
Female
Menstrual pattern ____________________ Date of LMP ____________________
Pregnancy history _________________________________________________________
Use of birth control measure: Yes _____ Type: __________________________
No _____ N/A
Monthly self-breast exam: Yes _____ No _____
External Genitalia Urethra Vaginal Discharge
Labia: Pinkish _____ Purulent _____
Symmetrical _____ Red/inflamed _____ Bloody _____
Asymmetrical _____ Foul smelling _____
Edema _____ Others:
Lesion _____ Swelling _____
Lumps/nodules _____
Breast
Equal___________ Unequal _____________ Tenderness________________
Surface:
Smooth _____ Retraction _____ Dimpling _____ Edema _____ Lesions _____
Masses at: ____________________
Others ____________________
6. Male
Prostate problems : Yes______ No________
Monthly testicular exam : Yes______ No________
Penis
Discharge________ Nodules/growths/lesions__________ Tenderness______________
Scrotum
Equal shape w/L lower than R _____ Non-tender _____ R/L enlargement _____
R/L undescended testes _____ Tenderness _____ Nodules/growths/lesions _____
Others: Hernia _____ Hydrocoele _____
H. COPING – STRESS TOLERANCE PATTERN
Have you experienced any recent stressful situations in addition to your illness/hospitalization? Yes _____ No _____
If “yes”, please describe briefly ______________________________________________________________________________
How do you usually manage stresses? _______________________________________________________________________
What do you do for relaxation? _____________________________________________________________________________
Support groups/counseling resources used ____________________________________________________________________
INSTRUCTION: Place an X to the specific area of abnormality during your Physical Assessment
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10. Cagayan de Oro City
Bachelor of Science in Nursing
HOSPITAL ROTATION
MANUAL
__________________________________
AREA OF ROTATION
Clinical Instructor:
_____________________________
Florig, Sharmaine Grace B.
Name of Student