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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______
Diagnosis:__________________________________________
None
Yes
Presence of Pain/discomfort:
CARE CONCERNS
Pain
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:
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
Swallowing
Risk For Injury
edema
acuity problems:___________
others:______________________
EARS:
discharges:_____
pain:_____
epistaxis
________________
MOUTH: Lips:
intact
cracked
others:____________________________
Mucus membrane:
moist
dry
others_____________
Dental:
decays ________
others______________
Tonsils:
pain
swelling:_______
occlusion
Others:________
hearing
lip color______
sores
uses dentures
lesions _________
chewing problem
others____________________
NECK:/THROAT:
hoarseness
tinnitus
speech difficulty
bleeding
gingivitis
swallowing difficulties
lump
lymph node
tenderness:____________
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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
Delirium
agitated
withdrawn
others:________________
Seizures:
No
______
SCI:level of injury:___
complete
Sensory
__tactile
discrimination
__2 pt
discrimination
__stereognosis
__graphesthesi
a
thought process
Others:_________
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
Syndrome:
Sp:________________
Impaired
deformities
Hand Grip:
L: ______
R:______
Foot pushes:
Physical Mobility
Impaired Bed
Mobility
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_______________
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
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-
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
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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:
char:____________
CVP leakage CVP level:____
varicosities __________
_____________
Hema:
bruising:___petechiae ___ ecchymosis
S1
___purpura
S2
Skin Integrity
regular
Others:
________
non-pitting
pitting
IV infiltration
fistula/shunts: loc
___ hematoma
reactions:_____________________
GIT and
GUT
Diet:
Diagnosis:___________________________________________
_________
oral type: ____________________preference: ______________
100%
75%
50%
25%
Constipation
25%
Diarrhea
25%
Bowel Elimination
yes
NGT
Swallowing
Fluid
___________ 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:
Last BM:___________
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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
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
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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:_______
pale
cyanotic
jaundiced
mottled
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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 ____
____________
Financial concerns(describe)_______________________________________________________________
Housing concerns:
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_______________________________________________________________________
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 ____________
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