a.

Physical Assessment:

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: Well-groomed Attire: Casual

Personal Hygiene: Body is maintained clean
Gait: Has upright posture and steady gait with opposing arm swing
Posture:
General Body Built: Average-looking

BEHAVIOR
Level of Consciousness:
(√) Awake ( ) Alert ( ) Lethargic
( ) Drowsy ( ) Stuporous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: A little bit happy Speech: Clear and was no presence of
speech blurring
Mood: In good mood Affect:

COGNITION

Oriented: (√)Person (√) Place (√) Time ( ) Confused ( )

Sedated
( √ ) Alert ( ) Restless ( ) Lethargic ( ) Comatose
Recent Memory:
Remote Memory:

THOUGHT PROCESS

Thought Content: ( ) Logical (√ ) Consistent

Client’s Perceptions: ( √ ) Reality-base ( ) Congruent with others
( √ ) Others: Aware of surroundings Suicidal
Thoughts/Ideation: ( ) Present (√ ) Absent

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: ( √ ) Normal ( ) Flushed ( ) Pale ( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others:

Texture: Smooth Tone: Pink skin tone

Lesions: ( ) Yes, site: (√ ) No
PALPATION
Moisture: Smooth Temperature: 36.5ºC
Turgor: Reverted to normal 1 sec after pinching
Edema: ( √ ) Absent ( ) Present, site:
( ) Mild ( ) Moderate ( ) Severe
Pruritus: ( ) Yes, site: ( √ ) No
Wound incision/pressure sore site: N/A Dressing type: N/A
Odor: ( √ ) None ( ) Mild ( ) Foul
Drainage/Exudates: ( ) Serous ( ) Sanguinous ()
Serosanguinous
Color: ( ) Yellow ( ) Creamy ( ) Green ( ) Beige/tan

NAILS
INSPECTION
Color: Light pink Texture: smooth texture Configuration: Concave
Symmetry: smooth and rounded Cleanliness: clean and neat
HEAD AND NECK
HEAD
INSPECTION
Head Structure and symmetry: Rounded; smooth skull contour
Hair Color: Light blond to black in color Thinning: ( ) Yes (√ ) No

PALPATION
Temporal Artery: Elastic and not tender
Cranium: No lumps and edema Scalp: No scaling, lesions, or lacerations
Hair Texture: Thick and silky
Maxillary & Frontal Sinuses: No lumps or swelling were felt during palpation

EYES
INSPECTION
Conjunctiva: R: Pink L: Pink Sclera: R: White L: White
Cornea: R: Clear L: Clear Iris: R: Black L: Black
Ptosis: R: N/A L: N/A
Visual Fields: R: 6 L: 6
Extraocular movements: : R: Coordinated, move in unison with parallel
alignment
L: Coordinated, move in unison with parallel
alignment
Pupil: Color: R: Black L: Black Size: R: 4 mm constricted, 7 mm dilated
L: 4mm constricted, 7 mm dilated Response to Light & Accommodation: R:
4 mm (constricted light), 7 dilated (dark)
L: 4mm (constricted light), 7 dilated (dark)

NOSE
INSPECTION
External Nose: No nasal deformities
Nostrils: R: Shape symmetrical with left nostril
L:. Shape is symmetrical with right nostril.

MOUTH
INSPECTION
Mouth & Throat Mucosa: Pale and dry Tongue: Tongue was pink with
whitish coating
Teeth and Gums: Complete set of teeth and gums is in pink color and firm,
not red and swollen
Floor of Mouth: Veins visible, Palate: No presence of lesions and
bumps Uvula: Uvula was hanging from the middle of the soft palate, pink in
color and round
Lesions and Ulcers: ( ) Yes, site: (√ ) No
Salivary Glands: No swelling
 FACE
INSPECTION
Spasms: ( ) Yes, site: (√ ) No
Tics: ( ) Yes, site: ( √ ) No
Lesions: ( ) Yes: ( ) Mild ( ) Moderate ( ) Severe ( √ ) No
Facial Paralysis: ( ) Yes R: L: ( √ ) No

EARS
INSPECTION
Tympanic membrane: R: Intact (√) Yes ( ) No L: Intact ( √) Yes ( ) No
Tragus of Ear: R: Flexible, no bumps and no tenderness. L: Flexible, no
bumps and no tenderness.
Canal: R: Intact and clean L: Intact and clean
Lesions: ( ) Yes, site: (√ ) No
Discharges: ( ) Yes, amount: ( ) Left ( ) Right ( ) Both ( √ )
No

NECK
PALPATION
Thyroid gland size: Not palpable Shape: Normal curve
Tenderness: N/A Nodules: N/A
Position of Trachea: Midline
Cervical Lymph Nodes: Non-palpable

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate:
Pattern: ( ) Shallow ( ) Dyspnea ( ) Tachypnea ( ) Shortness of
Breath
Chest Symmetry: ( √ ) Even ( ) Uneven
Chest Deformities: ( ) Scoliosis ( ) Kyphosis ( ) Kyposcoliosis
PALPATION
Chest: (
) Masses, site:
( ) Bulges, site:

( ) Muscle Tone, site:

( ) Crepitus, site:
( ) Areas of Tenderness, site:
( ) Subcutaneous Emphysema, site:
Excursion: ( ) Respiratory: R: cms. L: cms.

PERCUSSION
Notes elicited: N/A Site:
AUSCULTATION
Excursion: (√) Diaphragmatic: R: 4cms. L: 4cms.
Breath Sounds:
Normal: (√) Bronchial ( ) Bronchovesicular ( ) Vesicular
Adventitious: ( ) Crackles-Coarse, site:
( ) Crackles-Fine, site:
( ) Stridor, site:
( ) Rhonchi/Gurgles, site:
( ) Wheezes, site:
( ) Pleural Friction Rub, site:
Other Abnormal Findings: Voice Resonance:
( ) Bronchophony ( ) Egophony ( ) Whispered
( ) Pecteriloquy ( ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough: ( ) Yes: Type: ( ) Productive:
Color of Sputum: Amount:
( ) Non-productive
(√) No

CARDIOVASCULAR SYSTEM

NECK VESSELS
PALPATION
Carotid Artery: R: Pulsation is symmetry with left artery L: Pulsation is
symmetry with right artery
AUSCULTATION
Carotid Arteries: Bruits: ( √ ) Absent ( ) Present
Jugular Vein Distention: ( ) Yes: cms. ( √ ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): At the fifth intercostal space
Thrills: ( ) Present (√ ) Absent
PALPATION – Perfusion: Capillary Refill: Reverted to back to pink after 1.5
secs Murmurs:
N/A

PULSES
(√ ) Regular ( ) Strong ( ) Irregular ( ) Weak ( )
Absent
( ) Doppler ( ) Pacemaker
Radial: R: L:
Pedal: R: L:
Apical: R: 90 beats/minute L: 90 beats/minute
BP: 120/60 mmHg

GASTROINTESTINAL SYSTEM
Mouth: Oral mucosa appears light pink and moist with no lesions.
Throat: Tonsils pink in color

ABDOMEN
INSPECTION
Contour: Symmetrical contour and transverse incision from previous C/S
Symmetry: No unusual bumps and symmetrical in shape
Gastrostomy (specify): N/A
AUSCULTATION
Bowel sounds: ( √ ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany Rate: 20 per minute
PERCUSSION
Notes:
Site:
PALPATION
Abdomen: ( ) Tender ( ) Soft/Non-Tender( √ ) Firm ( ) Rigid
Mass: ( ) No ( ) Yes
Ascites: ( ) No ( ) Yes
Girth: 29 cm Inguinal Area: No lesion or bums were detected

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry: Bones, joints, muscles and limbs are equal in length, size, shape,
and color Deformities: N/A
Others:
Peripheral pulses:
Upper Extremities: Radial: R: Range in motion L: Range in motion
Ulnar: R: Range in motion L: Range in motion
Brachial R: Range in motion L: Range in motion
Lower Extremities: Popliteal: R: Range in motion L: Range in motion
Dorsalis Pedis: R: Range in motion L: Range in motion
Posterior Tibia: R: L: Range in motion
Edema: ( ) Yes ( )Pitting (Grade) (√ ) No
Temperature: 36.5ºC Site: Axillary
RANGE OF MOTION: ( √ ) Yes ( ) No, area:
Deformity: N/A
Discrepancy in Extremity (Leg) Length ( )Yes ( √ ) No
PALPATION
( ) Musculature ( ) Body articulation
( ) Crepitations ( ) Heat
( ) Swelling
( ) Tenderness
Normal ROM of extremities: ( √ ) Yes ( ) No
(√) Weakness ( Paresis) ( ) Paralysis
( ) Contractures ( ) Joint Swelling
( ) Pain: ( ) Bone Pain ( ) Muscle Pain ( ) Joint Pain
( ) Others:
Hand Grasps: (√) Equal ( ) Unequal ( )Weakness ( )R&
L Leg muscles: (√) Equal ( ) Unequal ( ) Weakness ( )R&
L

NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)
Can sense the smell the and resist at the same time

Optic Nerve (CN II)

Visual acuity 20/20 using Snellen chart

Oculomotor (CN III)

Eye movements (e.g., upward/medial, upward/lateral, medial,
downward/lateral) were present

Trochlear (CN IV)

Eyeball moves downward and laterally
Trigeminal Nerves (CN V)
Corneal reflexes present on both eyes during cotton wisp test

Abducens Nerve (CN VI)

Eyeball moves laterally

Facial Nerve (CN VII)

Facial movements are symmetrical and present by providing to taste sour
and sweet taste.

Acoustic Vestibulocochlear Nerve (CN VIII)

Hearing intact bilaterally to whispered voice, finger rub, questions being
asked (respond correctly), and hears a tick at 10 inches away from both
ears; no hearing deficiencies noted.

Glossopharyngeal Nerve (CN IX)

Patient taste is present and tongue was able to move from side-to-side and
up & down.

Vagus Nerve (CN X)

Gag reflex intact; swallow without difficulty.

Spinal Accessory Nerve (CN XI)

Head was able to turn side-to-side against a very light resistance from the
hands.

Hypoglossal Nerve (CN XII)

Tongue capable of protruding and can move side to side.

CEREBELLAR FUNCTION SENSORY SYSTEM

Discriminate Light Pain: (√) Yes ( ) No
Detect Vibration: (√) Yes ( ) No
Discriminate Light Touch: (√) Yes ( ) No
Detect Temperature: (√) Yes ( ) No
Detect Stereognosis: (√) Yes ( ) No
Detect Graphesthesia: (√) Yes ( ) No
Two-Point Discrimination: (√) Yes ( ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
2+_
Insertion Tendon of Triceps (C7 to C8)
_2+_
Insertion Tendon of Brachioradialis (C5 to C6)
_2+_
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_2+_
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
_2+_
 SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

_2+_
Cremasteric Reflex (L1 to L2)
_2+_
Plantar Reflex
_2+_

GENITOURINARY
PERIANAL REGION
INSPECTION

( ) Hemorrhoids: ( ) Bleeding ( √ ) Not

( ) Fissures ( ) Scars ( ) Lesions ( ) Rectal Prolapse
( ) Fistula ( ) Discharge ( ) Blood in stool

PALPATION
( ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution:
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance:

Bumps: ( ) Yes, site: ( ) No

Blisters: ( ) Yes, site: ( ) No
Lesions: ( ) Yes, site: ( ) No
Redness: ( ) Yes, site: ( ) No
Scrotum: R: L:
Urine: Color: Character:
Frequency per day: Amount:
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type):
Others (specify):

PSYCHOSOCIAL
Recent Stress: N/A
Coping Mechanism: Support System: Family
Calm: ( √) Yes ( ) No
Anxious: ( ) Yes (√) No
Angry: ( ) Yes (√) No
Withdrawn: ( ) Yes (√) No
Irritable: ( ) Yes (√) No
Fearful: ( ) Yes _ (√) No
Religion: Roman Catholic Restrictions: N/A
Feeling of Helplessness: ( ) Yes (√) No
Feeling of Hopelessness: ( ) Yes (√) No
Feeling of Powerlessness: ( ) Yes (√) No
Tobacco Use: ( ) Yes (√) No
Alcohol Use: ( ) Yes (√) No
Drug Use: ( ) Yes (√) No

NUTRITION
General Appearance: (√) Well Nourished ( ) Malnourished
( ) Emaniciated ( ) Other
Body Built: Average Weight: Height:
Diet: Regular Diet Meal Pattern:
( √ ) Feeds Self ( ) Assist ( ) Total Feed
Mastication/Swallowing Problem ( ) Yes (√ ) No
Dentures: ( ) Yes (√ ) No
Appetite: ( ) Increased ( √ ) Decreased ( ) Unusual
Decreased Taste Sensation: ( ) Yes ( √ ) No
Nausea: ( √) Yes ( ) No
Stool frequency: Once a day Characteristics: soft texture
Last Bowel Movement: NGT/ Gastrostomy: N/A

VENOUS ACCESS RECORD

Date Gauge (color)/

Date
# Site Inserte d Fluid Number of Reason
Removed
Drops
1

PAIN ASSESSMENT
Location of pain: Frequency:
Intensity Pain Scale (0-10): Quality:
Onset:
Duration: Body Reaction:
Alleviating Factors:
Precipitating factors:
Special Assessment Devices
( ) Wheelchair ( ) Contacts ( ) Venous Access device
( ) Braces ( ) Hearing aid ( ) Epidural catheter
( ) Cane/ Crutches ( ) Prosthesis ( ) Walker
( ) Glasses
Others:

SELF-CARE
Need Assist With:
( ) Ambulating ( ) Elimination
( ) Bed Mobility ( ) Meals
( ) Hygiene ( ) Dressing

PATIENT EDUCATION
( ) Safety / Restraint Us (√) Signs & Symptoms to Report
( ) Ordered Therapies ( ) Lifestyle Change
( ) Diagnosis / Disease ( ) Rehabilitation Measures
(√) Pain Management (√) Hygiene / Self care
(√) Hospital Referrals (√) Diet or Nutrition
( ) Community Referral ( ) Mobility / Ambulation
(√) Medication

Specify Plan of Care Intended:

Example medications (List Down all medications to be taken at home with
special nursing care instruction to be given to the client like, dosage, time,
frequency.