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

Page 1 of 18
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?

Page 2 of 18
 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 General mobility Posture
maintenance
Dressing Hand Grip

Functional Level Codes

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

Before During
Gordon’s Criteria Admission Admission

Page 3 of 18
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

Page 4 of 18
 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
Page 5 of 18
 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

Page 6 of 18
 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

Page 7 of 18
3.1 Head. Inspect size, shape, symmetry, position, hair distribution presence of
parasites, lice, dandruff and lesions

Page 8 of 18
 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

Page 9 of 18
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

Page 10 of 18
 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).

Page 11 of 18
 Tests Purpose Client’s Significance
Response
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

Page 12 of 18
 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

Page 13 of 18
 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.

Page 14 of 18
 Patient’s Findings

III. Laboratory / Diagnostic Result

Date and Name Abnormal Findings Significance

of Diagnostic
Test

IV. Summary of Findings

List of Nursing Problems (Not necessarily in order)

List of Prioritized Nursing Diagnosis (Please follow PES format)

Page 15 of 18
Rubrics
RATING SCALE FOR PERFORMANCE LEVEL
CRITERIA Excellen Good Fair NI
t 16 – 11 – 15 6 – 10 0-
20 5

NURSING/HEALTH Included and Provided few Provided Provided

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

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

Provided a complete Provided adequate Provided minimal Provided no

narrative physical physical physical physical
examination
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– 0-
10 5

LABORATORY Provided all the Provided all Provided Provided no

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

SUMMARY OF Listed all possible Listed adequate Listed few Listed nursing
FINDINGS nursing problems nursing problems nursing problems were
based on the based on the problems based incongruent to
nursing history, nursing history, on the nursing the nursing
Prioritization of physical physical history, physical history,
Nursing Problems assessment and assessment and assessment and physical
and Diagnoses laboratory results. laboratory laboratory assessment
Identified / results. Identified results. and laboratory
prioritized correctly / prioritized two Identified / results. Failed
three nursing nursing prioritized one to correctly
Page 16 of 18
diagnoses with diagnoses with nursing identify and
related factor related factor diagnoses with prioritize
utilizing the PES utilizing the PES related factor nursing
format format utilizing the PES diagnosis with
appropriately. appropriately. format. related factor.
PES format was
not well-stated.
TOTAL

Page 17 of 18
Page 18 of 18