SAN PEDRO COLLEGE

NURSING HEALTH ASSESSMENT GUIDE

Part I – HEALTH HISTORY

I.BIOGRAPHICAL DATA
Name of Client: ___________________________________________________________Age:___________Gender:__________
Ward,Unit:___________________________________Bed No.:____________Examiner:_________________________________
Home Address:____________________________________________________________________________________________
Birth Date:_____________________Place of Birth:____________________Nationality:____________Marital Status:_________
Educational Level:_______________Occupation:_________________No. of Dependents:______Religion:__________________

II.CURRENT HEALTH STATUS

Chief Complaint:____________________________________________Impression:_____________________________________
Attending Physician:___________________________Date of Admission:__________Manner of Admisssion:________________
ASK ABOUT: Symptoms experienced__________________________________________________________________________
Onset:________________Duration:________________Frequency:___________________Severity:________________________
Region/Radiation/Related Symptoms:________________________________Precipitating/Palliative Factors:________________
Remedies Given?Initial Treatment ( Before Consultation):_________________________________________________________
Consultation made When:__________________________Where:_______________________Whom:______________________

Notes:

III.PAST HEALTH HISTORY

Personal/Medical History
Arthritis Cancer Depression Diabetes Asthma/ Lung Problem
Heart Disease High Blood Pressure Psychiatric Disease Stroke Thyroid Problem
Epilepsy/Seizure Serious Injuries: (fractures, head injuries,motor accidents, burns, or lacerations)
Other/remarks:___________________________________________________________________________________________
Past Surgical Procedures: Please list previous surgeries with appropriate dates
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Previous Hospitalization/Visits
Reasons of Seeking Care: ___________________________________________Appropriate Date:________________________
Hospital/Health Institution: __________________________________________Physician:_______________________________
Treatment:_______________________________________________________________________________________________
Childhood Illnesses
Mumps Chicken pox Measles Poliomyelitis Ear Infections
Tonsillitis Asthma Diphtheria Others:_________________________________________
Medications: Prescription and non prescription medicines, vitamins, home remedies, birth control pills, herbs,etc.
Name of Drug Medication Dose (e.g mg/pill) How many times a day
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
Allergies or Drug Reactions: ________________________________________________________________________________
Immunizations: (Childhood)
BCG Hepatitis B DPT OPV Measles Others:________________________
Date of Recent Immunizations
Hepatitis A__________Hepatitis B__________Influenza(flu)__________Varicella__________HPV__________HTIG___________
Tetanus Toxioid__________Pneumonia__________others:________________________________________________________
Allergies: Please list any known allergies:_______________________________________________________________________
Other Concerns
Tobacco Use Cigarettes Never Quit Date:_____________________________________
Current Smoker: Packs/day:_______________No. of Years:________________________________
Alcohol Use Do you drink alcohol? No Yes, No. of drinks per week:__________________________
Drug Use Do you use recreational drugs? No Yes
Have you ever used needles to inject drugs? No Yes
 Sexual activity: Sexually active? Yes No Not Currently
Current Sex Partner(s) is/are: Male Female
Birth Control Method:______________________________________ None Needed
Have you ever had any sexually transmitted diseases (STDs)? No Yes, specify:_____________

Notes:

IV.FAMILY HISTORY
BROTHERS/SISTERS Gender Birthdate Deceased Cause of Death Genetically linked/ Details
(include half-siblings) (M/F) Common Diseases

MATERNAL SIDE
MOTHER GENDER BDATE Deceased Cause of Death Genetically linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS

PATERNAL SIDE
FATHER Gender BDATE Deceased Cause of Death Genetically Linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS
 V.GORDON’S FUNCTIONAL HEALTH PATTERNS à please follow provided for
A. Health Perception Pattern
B. Nutritional/ Metabolic Pattern
C. Elimination Pattern
D. Sleep/ Rest Pattern
E. Activity/Exercise Pattern
F. Cognitive/Perceptual Pattern
G. Values/Belief Pattern
H. Self-Perception/ Self-Concept Pattern
I. Roles/Relationship Pattern
J. Sexuality/Reproductive Pattern
K. Coping / Stress Tolerance Pattern

Note: Genetically-linked Diseases; Common Diseases- birth defects, specify—premature births –mental retardation, specify—diabetes—hearing loss—heart disease—seizures—
allergies—arthritis—obesity—cancer, specify
 SAN PEDRO COLLEGE
Davao City

NURSING DEPARTMENT

GORDON’S FUNCTIONAL HEALTH PATTERNS

I.HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

1. History
a. How was general health been?
b. Any colds in past year? When appropriate: absences from work?
c. Most important things you do to keep healthy? Think these things make a difference to health? (Include family folk remedies
when appropriate.) Use of cigarettes, alcohol, drugs? Breast self-examination?
d. Accidents (home, work, driving)?
e. In past, been easy to find ways to follow suggestions from physicians or nurses?
f. When appropriate: what do you think caused this illness? Actions taken when symptoms perceived? Results of action?
g. When appropriate: things important to you in your health care? How can we be most helpful?
2. Examination – general health appearance

II.NUTRITIONAL-METABOLIC PATTERN
1.History
a. Typical daily food intake?(Describe) Supplements (vitamins, type of snacks)?
b. Typical daily fluid intake? (Describe)
c. Weight loss or gain? (Amount). Height
d. Appetite?
e. Food or eating? Discomfort? Swallowing? Any diet restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems?
2. Examination
a. Skin: Bony prominences? Lesions? Color changes? Moistness?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth?
d. Actual weight, height.
e. Temperature
f. Intravenous feeding – parenteral feeding (specify)?

III.ELIMINATION PATTERN
1.History
a. Bowel elimination pattern? (Describe) Frequency? Character? Discomfort? Problem in control? Laxatives?
b. Urinary elimination pattern? (Describe) Frequency? Problem in control?
C, Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on? (specify)
2. Examination – when indicated: examine excreta or drainage color and consistency

IV.ACTIVITY-EXERCISE PATTERN
1.History
a. Sufficient energy for desired or required activities?
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure) activities?
Perceived ability (code level) for: Feeding___Dressing___Cooking___Bathing___Grooming___Shopping___Toileting___
General mobility___Bed mobility___Home maintenance___
Functional Level Codes:
Level 0: Full self-care
Level 1: Requires use of equipment or device level II : Requires assistance or supervision from another person
Level III: Requires assistance or supervision from another person and equipment or device
Level IV: is dependent and does not participate 2. Examination
2. Examination
a. Demonstrated ability (code listed above) for:
Feeding_____Dressing_____Cooking_____Bathing_____
Toileting_____Grooming_____Shopping_____General mobility_____
b. Gait_____Posture_____Absent body part? (specify) ______
c.Range of Motion (joints)__________Muscle firmness__________
d. Hand grip___________Pick up a pencil?___________
e. Pulse(rate)__________(rhythm)___________Breath sounds___________
f. Respirations(rate)___________(rhythm)___________Breatgh sounds_____________
g. Blood Pressure___________
h. General appearance(grooming,hygiene and general energy level)

V.SLEEP-REST PATTERN
1. History
a. Generally rested and ready for daily activities after sleep?
b. Sleep onset problems?Aids?Dreams? (nightmares)? Early awakening?
c. Rest relaxation periods?
2. Examination
a. When Appropriate: observe sleep rest pattern

VI.COGNITIVE – PERCEPTUAL PATTERN

1.History
a. Hearing difficulty? Hearing aid?
b. Vision? Wear glasses? Last checked? When last changed?
c. Any changed in memory lately?
d. Important decision easy or difficult to make?
e. Easiest for you to learn things? Any difficulty?
f. Any discomfort? Pain? When appropriate: How do you manage it?
2. Examination
a. Orientation
b. Hears whisper?
c. Reads newsprint?
d. Grasps ideas and questions (abstract, concrete?)
e. Language spoken
f. Vocabulary level. Attention span.

VII.SELF-PERCEPTION/SELF-CONCEPT PATTERN
1.History
a. How describe self? Most of the time, feel good (not so good) about self?
b. Changes in body or things you can’t do? Problem to you?
c. Changes in way you feel about self or body ( since illness started)?
d. Things frequently make you angry?Annoyed? Fearful? Anxious?
e. Ever feel you loose hope?
2. Examination
a. Interaction with family member(s) or others (if present)

VIII.ROLES/RELATIONSHIP PATTERN
1.History
a. Live alone? Family? Family structure (diagram)?
b. Any family problems you have difficulty handling (nuclear or extended)
c. Family or others depend on you for things? How managing?
d. When appropriate: How family or others feel about illness or hospitalization?
e. When appropriate: Problems with children? Difficulty handling?
f. Belong to social groups? Close friends? Feel lonely (frequency)?
g. Things generally go well at work? (school)?
h. When appropriate: income sufficient for needs?
i. Feel part of (or iso;ated in) neighborhood where living?
2. Examination
a. Interaction with family member(s) or others (if present)

IX. .SEXUALITY/REPRODUCTIVE PATTERN

1.History
a. When appropriate to age and situations: Sexual relationships satisfying? Changes? Problems?
b. When appropriate: Use of contraceptives? Problems?
Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?
2. Examination
a. None unless problem identified or pelvic examination is part of physical assessment

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X.COPING/STRESS TOLERANCE PATTERN
1.History
a. Any big changes in your life in the last year or two? Crisis?
b. Who’s most helpful in talking things over? Available to you now?
c. Tense or relaxed most of the time? When tense, what helps?
d. Use any medicines,drugs, alcohol?
e. When(if) have big problems (any problems) in your life, how do you handle them?
f. Most of the time is this (are these) way(s) successful?
2. Examination: None

XI.VALUES/BELIEFS PATTERN
1.History
a. Generally get things you want from life? Important plans for the future?
b. Religion important in life? When appropriate: Does this help when difficulty arise?
c. When appropriate: Will being here interfere with any religious practices?
2. Examination: None

OTHER CONCERNS
1.Any other things we haven’t talked about that you would like to mention?
2. Any questions?

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I.GENERAL SURVEY NOTES
Body Built Endomorph
Mesomorph
Ectomorph
Height ___cm Weight ___(kg)
Posture / Gait Lordosis
Kyphosis
Scoliosis
Shuffling
Physical Defects, specify
LOC Alert Drowsy Obtunded Stuporous Comatose
Verbal Response Oriented Confused Inappropriate
Incomprehensible None
Grooming well – groomed
disheveled
Orientation oriented
disoriented
Mood appropriate
inappropriate
Vital Signs:
Temperature:________________
Heart Rate:__________________
Pulse Rate:__________________
Respiratory Rate:_____________
Blood Pressure:______________
Pain (PQRST)

II.SKIN NOTES
General Color Uniform Pallor Jaundice
Flushed Cyanotic Bronzing/Tanning
Texture Smooth Rough
Turgor Good Fair Poor
Temperature Warm Cool
Moisture Dry Clammy oily
Lesions: Primary Secondary Vascular
Edema: Pitting Non- pitting
Ulceration:
Exudate Type None Serous Serosanguinous
Purulent Foul purulent
Surrounding Skin: Pink/skin tone reddish/blanchable
white/pallor purple black
Nails well-trimmed jagged edges paronychia koilonychia

III.HEAD NOTES
Configuration Normocephalic Masses
Fontanelles Closed Open
Sunken Bulging
Skull Symmetrical Deformities Depression
Lumps Tenderness
Scalp Clean Dandruff Lice Lesions
Hair Normal Distribution Alopecia
Fine Coarse
Dry Oily
Infestation Hirsutism
Face Symmetrical Movements
Asymmetrical Movements
Involuntary Movements
Paralysis Edema Masses
Muscle Strength of Jaw Normal
Decreased Absent
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IV.EYES NOTES
Structure
Eyebrows Aligned Scaly
Symmetrical movements Asymmetrical Movements
Lids Symmetrical Edema Ptosis
Lashes Curled Inward Curled Outward
Lacrimal Duct Normal Swelling
Excessive Tearing Dry
Cornea and Lens Smooth Clear
Lesions Opacity Arcus Senilis
Conjunctiva Pinkish Pale Lesion
Periorbital Region Edema Sunken Discoloration
Sclera Anicteric Icteric Bloodshot
Pupil Isocoric Anisocoric
Reaction to Light
OD Brisk Sluggish Fixed
OS Brisk Sluggish Fixed
Reaction to Accommodation Uniform Unequal
EOMs Normal Nystagmus
Convergence Uniform Unequal
Visual Acuity Grossly Normal with Corrective Lenses
Functional Vision Counting Fingers Hand Movement
Light Perception
Visual Fields Homonymous Hemianopsia
Bitemporal Hemianopsia
Quadrantic Effects

V. EARS NOTES
Pinna Normoset Symmetrical Tenderness
External Canal Impacted Cerumen Discharges
Foul Smelling Serous Purulent Mucoid
Tympanic Membrane (optional) Pearly- Gray Pinkish
Hearing Acuity Normal Deaf

VI.NOSE NOTES
Nasolabial Fold Symmetrical Asymmetrical
Septum Midline Deviated Perforated
Mucosa Pinkish Pale Reddish
Blood Crusts Ulceration
Discharge Serous Purulent
Mucoid Bloody
Patency Both Patent Obstructed
Lesions
Sinuses Non Tender Tender

VII. MOUTH NOTES

Lips Symmetrical Asymmetrical
Color Pinkish Pale Cyanotic
Moisture Moist Dry/Crack
Lesions
Tongue Midline Deviation
Atrophy Fasciculation Lesions
Teeth Complete Missing
Dentures Braces Caries
Discoloration
Gums Pinkish Pale
Bleeding Tender
Mucosa Pinkish Pale
Cyanotic Lesion
Palate Pinkish Pale
Reddish Swelling
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VIII.PHARYNX NOTES
Uvula Midline Deviated
Mucosa Pinkish Pale Reddish
Swelling Ulceration
Tonsils Not Inflamed Inflamed
Gag Reflex Positive Negative

IX. NECK NOTES

Trachea Midline Deviated
Lymph Nodes Nonpalpable Palpable/enlarged Tender
Thyroid Nonpalpable Enlarged
Tender Bruit
ROM Normal Rigid
Jugular Vein Distention Present Absent
Muscle Strength Normal Decreased

X.THORAX NOTES
Shape Symmetrical Asymmetrical
Barrel Chest Pigeon Chest Funnel Chest
Spinal Alignment Normal Deformed
Others Bulges Tenderness Lesion
Breathing Pattern Effortless Bradypnea
Tachypnea Dyspnea
Hyperventilation Hypoventilation
Use of accessory muscles
Chest skin Turgor Good Poor
Respiratory Excursion Symmetrical Asymmetrical
Tactile Fremitus Symmetrical Increased Decreased
Percussion Resonant Dull Hyperresonant
Diaphragmatic Excursion ________________R/L (cm)
Breath Sounds Bronchial Vesicular Bronchovesicular
Adventitious Breath Sounds Wheezes Rales/Crackles
Ronchi Friction Rub

XI. HEART NOTES

Precordium Normodynamic Tenderness
Heave Thrill
Heart Sound Distinct Faint
Aortic
Pulmonic
Tricuspid
Apical
Extra Sounds S3 S4 Murmur
Pulse
Temporal Thready Weak Strong Absent
Carotid Thready Weak Strong Absent
Apical Thready Weak Strong Absent
Brachial Thready Weak Strong Absent
Radial Thready Weak Strong Absent
Popliteal Thready Weak Strong Absent
Dorsalis Pedis Thready Weak Strong Absent
Posterior Tibia Thready Weak Strong Absent
Calf Tenderness (Homan’s Sign) Right Positive Negative
Left Positive Negative

XII. BREAST NOTES

Size and Symmetry Equal Unequal
Contour Masses Dimpling
Skin Redness Edema
Tenderness Non-tender Tender
Nipple and Areola Inversion Retraction Edema
Color: _____________________
Discharge: Serous Purulent Mucoid Bloody
XIII. ABDOMEN NOTES
Skin Intact Striae Scars Lesions
Contour Flat Globular Distended
Abnormalities:
Masses Visible Peristaltic wave
Visible Pulsations Bladder Distention
Bowel Sounds
Normoactive Hyperactive
Hypoactive Absent
Vascular Sound Bruit
Friction Rub Absent Present
Percussion Tympanic Hypertympanic
Liver Size: _____________cm (MCL & MSL)
Bladder Palpable Nonpalpable
Ascites Positive Negative
Palpation Muscle Guarding

XIV. GENITO-URINARY SYSTEM NOTES

Female
Pubic Hair Normal Scanty
Labia Symmetrical Assymetrical
Lesions Pinkish
Discoloration Edema
Vagina Discharge
Purulent
Bloody
Foul smelling
Others: swelling Lumps/Nodules
Male
Penis Well - developed
Lesions
Tenderness
Discharge
Purulent
Bloody
Foul Smelling
Meatus Midline Epispadia Hypospadia
Scrotum Symmetrical Asymmetrical
Lesions Tenderness
Enlargement Cryptorchidism
Others Hernia Hydrocele

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 SAN PEDRO COLLEGE

PHYSICAL ASSESSMENT GUIDE

Part III – MUSCULOSKELETAL & NEUROLOGICAL ASSESSMENT

MUSCLES: Assess muscles supporting interphalangeal, NOTES

metacarpophalageal, wrist, elbow, shoulder, metatarsophalangeal, ankles,
knees, and hip joints. Specify which muscles correspond to findings,
Size equal disproportionate atrophy
hypertrophy contractures tremors
flaccidity spasticity
Specify:______________________________________________________
Test for MUSCLE STRENGTH (Compare L/R)
___sternocleidomastoid ___trapezius ___biceps
___triceps _____finger/wrist ____hip muscles (raising)
___hip muscles (abduction/adduction) ___hamstring
____quadriceps ___ankles/feet
Weakness at_________________________________________________
Numbness/Tingling at__________________________________________

Grade Description
0 No muscular contraction detected
1 A barely detectable trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against some resistance
5 Active movement against full resistance

BONES: Inspect and palpate SKELETAL structure and tenderness. Specify NOTES
which bone corresponds to findings.
Symmetrical strength gross asymmetry
deformity tenderness
Specify:____________________________________________________

JOINTS. Assess interphalangeal, metacarpophalangeal, wrist, elbow, NOTES

shoulder, metatarsophalangeal, ankles, knees, and hip joints. Specify
which joint corresponds to findings.
symmetrical Bony abnormalities
redness crepitation warmth
swelling tenderness
Specify: ___________________________________________________
Assess Range of Motion of joints (Head to Toe). Specify which joint and
what movement.
Full range of Motion
Specify (joint/movement): ---------------
____________________________________________________________
____________________________________________________________
____________________________________________________________
decreased range of motion
Specify (joint/movement):______________________________________
____________________________________________________________
____________________________________________________________
Others: _____________________________________________________
NEUROLOGICAL ASSESSMENT. Mental status NOTES
Assess speech and language. Briefly describe findings.
Spontaneity__________________________________________________
Ease and enunciation__________________________________________
Sophistication________________________________________________
Check for abnormality.
hesitancy stuttering slurred
aphasia, type_________________________________________
Others_________________________________________________
______________________________________________________
Determine: ORIENTATION – time, place, and person
oriented disoriented specify___________________
Check for LAPSES IN MEMORY. Describe.
Immediate/ short term memory_________________________________
Recent Memory______________________________________________
Remote Memory______________________________________________
Attention Span_______________________________________________
LEVEL OF CONSCIOUSNESS
oriented disoriented specify___________________