CEBU INSTITUTE OF TECHNOLOGY

UNIVERSITY

COLLEGE OF NURSING

HEALTH ASSESSMENT TOOL

Name of Student: Rogail R. Genturalez Level 3 Section N1 Rating: ______

I. Nursing Health History

A. Biographic Data
Initials of Client/Patient : B.S.M
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:

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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
Patient B.S.M is male. His facial features are symmetric, decrease mental alertness, he
doesn’t responds well to questions and is uncooperative, he has ineffective cough.

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

Patient’s Findings
Skin turgor is normal, has dark spots, dry skin. Nails has dark soiled. Tempersture is within
normal range. No presence of lesions.

3. HEAD, FACE AND NECK

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

Patient’s Findings
Head size is normal and structuce. Facial features are symmetric. Hair distribution is
normal with no presence of parasite, or lice, dandruff and lesions.

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
Nose is in midline and symmetry, no discharges, there is flaring, both nares are patent,
nasal septum in the midline and not perforated, nasa, mucosa is pinkish in color

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
Lips are dry and cracked, ventral surface is smooth, shiny and not pinkish in color.

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
Eyeball is symmetrical in size and position, upper lids cover the upper portion of the cornea
when the patient is looking straight.

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

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 Patient’s Findings

no middle ear infection, proper ear alignment in both sides, no presence of inner ear
infection, no discharges noted, no skin tags.
6. LUNGS

Patient’s Findings

Patient has difficulty in breathing, diminished breath sounds, barrel chest, ineffective
cough, presence of gurgling sound while NGT feeding.

7. CARDIOVASCULAR

Patient’s Findings
Not assessed.

8. MUSCULOSKELETAL
8.1 Inspection and Palpation (Gait, cervical, thoracic and lumbar curves. Palpate spinous
processes and paravertebral muscles on both sides of the spine).

Patient’s Findings

Not assessed.

10. GENITOURINARY

10.1 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

Not assessed.

11. ANAL AREA

11.1 Inspect the perianal area for lumps, ulcers, lesions, rashes, redness fissures and thickening
of the epithelium.

Patient’s Findings

Not assessed.

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