Cebu Institute Of Technology – University

COLLEGE OF NURSING

HEALTH ASSESSMENT TOOL

Name of Student: _____________________________ Level __ Section __ Rating: ______

I. Nursing Health History

A. Biographic Data
Initials of Client/Patient :
Residence: _____________
Contact Number: Nationality:
Religion : Birth of Date:
Age: Sex: Civil Status:
Educational Attainment: ______
Occupation: _____________

Name of Hospital: ___________________ Ward & Room No.:

Date of Admission: Attending Physician :

Impression / Admitting Diagnosis:

__________________________
Source of Information:
( ) Patient
( ) Others, (Initials of SO):
Relationship to patient :

B. Admitting Complaint/s _________________________________________________________

_______________________________________________________________________________

Vital Signs: Temperature: ______ PR: ______ RR: _______

BP: ______________ Pain Score: ______

C. History of Present Illness

Symptom: ______
Location: ______
Character: ______
Intensity: ______
Timing: _____________
Aggravating factors:
Alleviating factors:
Treatments tried:

D. Review of Systems

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E. Past and Present Medical History (Utilizing Gordon’s Functional Health Pattern).
Questions are being included so that students will be guided with each health patterns. Please
answer the following inquiries.
Before During
Gordon’s Criteria Admission Admission
I. HEALTH PERCEPTION HEALTH MANAGEMENT
PATTERN
1. How was general description of the client’s
health prior to hospitalization or
consultation?
2. Any childhood or past year illnesses (both
physiologic and psychiatric alterations)?
Any absences from work if client or patient
is working?
3. The most important things the client/patient
do to keep healthy? Use of cigarettes,
alcohol, drugs?

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 4. Accidents or injuries (home, work, driving)?
Any operations, treatments and
medications
received?
5. In past, are there any health suggestions
that were easy for the patient to comply?
what do you think causes this complaint?
Actions taken when symptoms perceived?
Results of action?
II. NUTRITIONAL-METABOLIC PATTERN
1. Describe the typical daily food intake?
Supplements (vitamins, type of snacks)?
2. State the weight of the patient in relation
to the height and the significance of his
weight to his height?
Before During
Gordon’s Criteria Admission Admission
3. Can the patient consume his food during
meal or snack time? If not, why?
4. If the patient has wound, does it heal well
or poorly? Any skin problems like lesions,
dryness and dental problems?
III. ELIMINATION PATTERN
1. Describe the urine and bowel elimination
pattern? Frequency? Character?
Discomfort? Problem in control? Use of
laxatives as over the counter drug or
prescribed? Odor problems?
2. Any body cavity drainage, suction, and so
on that aids the patient in elimination?
IV. ACTIVITY-EXERCISE PATTERN
1. Is there sufficient energy for desired or
required activities?
2. Does the patient exercise regularly? What
type of exercise?
3. What are the patient’s activities in their
spare-time / leisure time? If the patient is a
child, what play activities does he indulge
in?
4. Perceived ability (code for level) for:

Criteria Rate Criteria Rate Criteria Rate

Feeding Gait Cooking
Bathing ROM Shopping
Toileting Grooming Bed mobility
Home maintenance General mobility Posture
Dressing Hand Grip

Functional Level Codes

*Level 0: full self-care *Level III: requires assistance or
*Level I: requires use of equipment supervision from another
or device person and equipment or
*Level II: requires assistance or device
supervision from another *Level IV: is dependent and does not
person participate

Before During
Gordon’s Criteria Admission Admission
V. SLEEP-REST PATTERN
1. Can the patient rest/sleep? What are the
usual daily activities of the patient to
induce him to sleep?
2. Are there sleep onset problems? Aids?
Dreams (nightmares)? Early awakening?
VI. COGNITIVE-PERCEPTUAL PATTERN

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 1. Any hearing difficulty? Presence of hearing
aid? Location: Left or right or both?
2. Is there a problem in vision? Wear glasses?
Last checked? When Last changed?
3. Any change in memory lately?
4. Does the patient experience difficulty in
deciding during problems, family issues,
etc. ?
5. What are the patient’s strategies to make
decisions easier?
6. Any discomfort? Pain? When appropriate:
How do you manage it?
Before During
Gordon’s Criteria Admission Admission
VII. SELF-PERCEPTION—SELF-CONCEPT PATTERN
1. How will the patient describe self?
2. Changes in way the patient feel about self
or body (since illness started)?
3. Things frequently make the patient angry?
Annoyed? Fearful? Anxious?
4. Ever feel that the patient lose hope?
VIII. ROLES-RELATIONSHIPS PATTERN
1. Is the patient living alone? With family?

Draw the family structure or genogram with emphasis

on the specific heredo familial diseases.

Before During
Gordon’s Criteria Admission Admission
2. Any family problems you have difficulty
handling (nuclear or extended)?
3. Are the family or others depend on the
patient for things? How is the patient
managing?
4. How do the family or others feel about
illness or hospitalization?
5. Are problems with children also the
concern of the patient? Does the patient
have difficulty in handling the problems?
6. Is the patient belongs to social groups?
Close friends? Is the patient lonely?
7. Are things generally go well at work or
school?
8. Does the income sufficient for their needs?
IX. SEXUALITY-REPRODUCTIVE PATTERN
1. When appropriate to age and situations:
Does the patient’s sexual relationships

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 satisfying? Any changes? or problems?
Use of contraceptives? Problems?
2. If client is female and of age: When
menstruation started (menarche)?
Duration? Menstrual cycle?
3. Last menstrual period, if with relation?
Menstrual problems?

G___ T___ P _ A L___ M___

Before During
Gordon’s Criteria Admission Admission
X. COPING-STRESS TOLERANCE PATTERN
1. Is there any big changes in the patient’s
life in the last year or two? Any crisis?
2. Who is the most helpful in talking things
over? Is this person available to you at
present?
3. Is the environment tense or relaxed most
of the time? When tense, what coping
strategy helps?
4. How do the person handle stress? Use any
medicines, drugs, alcohol?
5. Is the coping strategies successful?
XI. VALUES-BELIEFS PATTERN
1. Important health plans for the future?
2. Is religion important in life? When
appropriate: Does this help when
difficulties arise? Does religion interfere
with health practices?
3. Any other values or beliefs that affect the
health care delivery system.
XII. Other concerns: Any other things we haven’t
talked about that you would like to mention?
Any questions?

II. Physical Assessment

1. GENERAL SURVEY: Describe the general appearance apparent age, grooming, hygiene, odors,
nutritional status, level of consciousness, speech, affect, gait, posture, movements, gross
deformities and signs of distress.

Patient’s Findings

2. SKIN AND NAILS. Inspect the color and presence of lesions. Palpate temperature, turgor and
texture.

Patient’s Findings

3. HEAD, FACE AND NECK

3.1 Head. Inspect size, shape, symmetry, position, hair distribution presence of parasites, lice,
dandruff and lesions

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 Patient’s Findings

3.2 Face. Inspect symmetry of nasolabial folds and palpebral fissures. Palpate muscle of
mastication and test sensory function (CN V). Note facial mobility (CN VII).

Patient’s Findings

3.3 Neck. Inspect, palpate and auscultate thyroid. Palpate lymph nodes and tracheal position.
Note ROM of neck. Test neck muscle strength (CN XI)

Patient’s Findings

4. NOSE, MOUTH AND THROAT.

4.1 Nose and Sinuses. Inspect nasal mucosa, septum and turbinates. Palpate sinuses and nasal
patency. Test sense of smell (CN I).

Patient’s Findings

4.2 Mouth. Inspect lips, oral mucosa, teeth, gums and tongue. Test sense of taste (CN VII, IX).
Test mobility of tongue (CN XII) and gag reflex (CN IX, X)

Patient’s Findings

5. EYES AND EARS

5.1 Eyes. Test visual acuity with Snellen Chart or allowing the client to read a magazine (CN II),
Peripheral vision by confrontation, EOM in 6 cardinal fields (CN III, IV, VI), Corneal light
reflex, Cover/uncover test. Inspect external structures of the eye, test pupillary reaction,
and palpate lacrimal glands / ducts

Patient’s Findings

5.2 Ears. Inspect/palpate external ear, perform whisper tests (CN VIII)
Patient’s Findings

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6. LUNGS
6.1 Inspection. Respiratory effort or rate, anteroposterior-lateral ratio and condition of the skin
in the thoracic.

Patient’s Findings

6.2 Palpation. Symmetric chest expansion, presence of tenderness, masses, crepitus and tactile
Fremitus
Patient’s Findings

6.3 Percussion. Anterior/posterior/lateral and diaphragmatic excursion.

Patient’s Findings

6.4 Auscultation. Note for breath and adventitious sounds and count apical pulse.

Patient’s Findings

7. CARDIOVASCULAR
7.1 Inspection. Presence of carotid and jugular pulsations.
Patient’s Findings

7.2 Palpation. Note apical impulse.

Patient’s Findings

7.3 Auscultation.
Patient’s Findings

8. BREASTS
8.1 Inspection. Observe the size, color, texture, symmetry and superficial venous pattern of
the breasts. Inspect the areola for color, size, shape, texture of both breasts as well as
retraction and dimpling.
Patient’s Findings

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 8.2 Palpation. For tenderness, temperature and mass. Squeeze the nipples gently to note
discharges.
Patient’s Findings

9. ABDOMEN
9.1 Inspection. For contour, symmetry, bulging, mass color, scars, straie, presence of hernias,
vascular changes, presence of lesions or rashes. Observe abdominal pulsations and
presence of umbilicus deviation.
Patient’s Findings

9.2 Auscultation. Auscultate bowel sounds, vascular sounds, and friction rub.
Patient’s Findings

9.3 Percussion. Assess the four quadrants for abnormal abdominal sounds, span or height of
the liver, presence of ascites as well as blunt percussion on kidney.
Patient’s Findings

9.4 Palpation. Assess the four quadrants presence of tumors, deviations of umbilicus,
abnormal pulsations, and liver
Patient’s Findings

10. MUSCULOSKELETAL
10.1 Inspection and Palpation (Gait, cervical, thoracic and lumbar curves. Palpate spinous
processes and paravertebral muscles on both sides of the spine).
Patient’s Findings

10.2 Perform the following tests (If the present condition allows).

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 Tests Purpose Client’s Response Significance
Nudge Test

Phalen’s Test

Tinel’s Test

Bulge Test

Test for ROM

Head, spinal cord,
lower extremities
(feet, ankles and
knees)

Upper extremities,
(arms and hands),
shoulders

11. NEUROLOGIC
11.1 Assess mental status and level of consciousness.
Patient’s Findings

11.2 Observe posture and body movements. Be alert for tense, nervous, fidgety, and restless
behavior which reflect apprehension during physical exam.

Patient’s Findings

11.3 Observe facial expressions as well as eye contact and affect. Note also speech (clarity,
tone and pace of speech), dressing (grooming and hygiene), mood (feelings and
expressions), cognitive abilities, orientation, memory and rationalization on issues.
Patient’s Findings

11.4 Cranial Nerve Test

Name of Nerve Function Client’s Response and Significance
1 Olfactory

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 2 Optic

3 Oculomotor

4 Trochlear

5 Trigeminal

6 Abducens

7 Facial

8 Auditory

9 Glossopharyngeal

10 Vagus

11 Accessory

12 Hypoglossal

11.5 Test for Reflexes (Biceps, Brachioradialis, Triceps, Patellar, Achilles Tendon and Plantar
Tests).

0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: non-sustained clonus
5+: sustained clonus

11.6 Other Tests

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 Test Purpose Client’s Response and Significance
Kernig’s Sign

Brudzinski’s Sign

12. GENITOURINARY

12.1 Inspection. Note distribution of pubic hairs and presence nits/lice. For female: Observe
perineum, labia, clitoris, urethral meatus, vaginal opening, Bartholin’s glands for lesions,
swelling and excoriation as well as enlarged nodes. For male: Inspect skin of penile shaft
for rashes, lesions or lumps, foreskin, glans penis and meatus for color, location and skin
integrity. Also observe the size, shape and position of the scrotum and its skin, any
presence of hernia.

Patient’s Findings

12.2 Palpate hypogastrium gently for urine retention and presence of abnormal mass or growth
Patient’s Findings

12.3 Auscultate labia or the scrotal area for presence of bowel sounds.

Patient’s Findings

13. ANAL AREA

13.1 Inspect the perianal area for lumps, ulcers, lesions, rashes, redness fissures and thickening
of the epithelium.
Patient’s Findings

13.2 Ask the client to perform Valsalva’s maneuver (bearing down) to note any bulges.

Patient’s Findings

13.3 Palpate the prostate gland (if allowed and with the presence of the clinical instructor) by
using the index finger facing toward the umbilicus. Note the size, shape, consistency and
identify nodules.

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 Patient’s Findings

III. Laboratory / Diagnostic Result

Date and Name of Abnormal Findings Significance

Diagnostic Test

IV. Summary of Findings

List of Nursing Problems (Not necessarily in order)

List of Prioritized Nursing Diagnosis (Please follow PES format)

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Rubrics
RATING SCALE FOR PERFORMANCE LEVEL
CRITERIA Excellent Good Fair NI
16 – 20 11 – 15 6 – 10 0-5

NURSING/HEALTH Included and supplied Provided few Provided elements Provided elements
HISTORY answers to all 31 elements of of biographical of biographical
elements of biographical data, data, admitting data, admitting
biographical data, admitting complaints complaints and complaints and
admitting complaints and history of history of present history of present
and history of present present illness, illness, however illness, however
illness or complaints. however missed at missed at least 15 missed at least 23
least 7 items items needed to items needed to
needed to complete complete the data. complete the
the data. data.

Past and Present Narrated effectively Addressed the 9 Answered the 6 Completed the 3
Medical History and correctly all 12 components of the components of the components of the
(Gordon’s Functional functional health functional health functional health functional health
Health Patterns) patterns of patterns of the patterns of the patterns with
assessment, following assessment in assessment in gross deficiencies.
the correct or proper narrative with minor details or has
format with no grammatical errors, significant
grammatical or spelling spelling, or grammatical and
errors. Consistently formatting errors. spelling errors.
placed rationale and Placed rationale and Placed rationale
significance to significance to and significance to
findings. almost all of the some of the
findings. findings.

Provided a complete Provided adequate Provided minimal Provided no

narrative physical physical examination physical physical
PHYSICAL examination documentation that examination examination
ASSESSMENT documentation that covers majority of documentation documentation.
covers all systems systems with with numerous
using the four skills in minimal grammatical,
assessment without grammatical, spelling or word
grammatical, spelling spelling or word usage errors. No
or word usage errors. usage errors. evidence of
Evidence of Evidenced of further
appropriate appropriate assessment of
assessment of assessment of negative findings.
negative findings negative findings
documented. documented.

RATING SCALE FOR PERFORMANCE LEVEL

CRITERIA Excellent Good Fair NI
16 – 20 11 – 15 6 – 10 0-5

LABORATORY Provided all the latest Provided all Provided laboratory Provided no
RESULTS laboratory results, the laboratory results results with no laboratory results
reference ranges and with normal ranges, normal ranges or normal values
demonstrated however limited number of and significance.
understanding of the significance of its labs as well as
significance as they abnormal results significance of the
apply to patient’s were not results were not
history/illness. consistently stated. mentioned or
included.

SUMMARY OF Listed all possible Listed adequate Listed few nursing Listed nursing
FINDINGS nursing problems nursing problems problems based on problems were
based on the nursing based on the the nursing history, incongruent to
history, physical nursing history, physical the nursing
Prioritization of assessment and physical assessment assessment and history, physical
Nursing Problems and laboratory results. and laboratory laboratory results. assessment and
Diagnoses Identified / prioritized results. Identified / Identified / laboratory results.
correctly three nursing prioritized two prioritized one Failed to correctly
diagnoses with related nursing diagnoses nursing diagnoses identify and
factor utilizing the PES with related factor with related factor prioritize nursing
format appropriately. utilizing the PES utilizing the PES diagnosis with
format format. related factor.
appropriately. PES format was
not well-stated.
TOTAL

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