Nursing Admission Assessment Template Page 3
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5' ' ' '
Eyes:
NSF
'
'
Blurred Vision '
'
Double vision '
'
'
'
Inflammation
Pain
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
Color blind
Itching
Pupils abnormal
Yes
No
Yes
No
Yes
No
'
'
'
'
Drainage -- Color ____________ Amount ____________
Other
___________________________________
Yes
No
Yes
No
' ' ' '
Ears:
NSF
'
'
(L) '
'
'
'
'
'
HOH (R)
Deaf
Tinnitus
Dizziness
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
Drainage _________________________
sense of balance
Pain
Yes
No
Yes
No
Yes
No
'
'
Other ______________________________________________________________________________________________
Yes
No
' ' ' '
Nose:
NSF
'
'
'
'
'
'
Congestion
Pain
Sinus problems
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
Nasal Flaring
Alignment
Nosebleeds – frequency
___________________________
Yes
No
Yes
No
Yes
No
'
'
Drainage – color _______________________________________amount
______________________________________
Yes
No
'
'
Other _____________________________________________________________________________________________
Yes
No
' ' ' '
Mouth:
NSF
'
'
'
'
'
'
'
'
Halitosis
Pain
Bleeding gums
Lesions
Yes
No
Yes
No
Yes
No
Yes
No
9
'
'
sense of taste
Yes
No
Dental Hygeine ______________________________________ Last Dental Exam
__________________________________________
' ' ' '
Throat/Neck:
NSF
'
'
'
'
'
'
'
'
Sore throat
Hoarseness
Lumps
Swollen glands
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
Stiffness
Pain
Dysphagia
Yes
No
Yes
No
Yes
No
'
Other
___________________________________________________ _________________________________________________
' ' ' '
Neurological:
NSF
'
'
'
'
Cooperative
Memory Changes
Yes
No
Yes
No
'
'
'
'
Dizziness
Headaches
Yes
No
Yes
No
'
'
'
'
Oriented
Other _________________
Yes
No
Yes
No
'
'
Person '
'
Place '
'
Oriented to:
Time
Yes
No
Yes
No
Yes
No
Pupils
Size: __________________ Deviation: _____________________
'
'
PEARLA
Yes
No
'
'
'
Reaction:
Brisk
Sluggish
No Response
'
'
'
'
'
LOC
Alert
Confused
Sedated
Somnolent
Co
'
'
matose
Agitated
Other _____________
'
'
'
'
'
'
Speech
Clear
Slurred
Aphasic
Dysphasia
None
Other: _____________________
'
Grips: _______________ Foot pushes: ________________
Gag reflex: ___________________
Other: _____________________
' ' ' '
Respiratory:
NSF
Lung sounds: _________________________________________________________________________________________________
'
'
'
'
'
Dyspnea
None
With activity
At rest
Lying down
Retractions
'
'
'
Cough
None
Non-productive
Productive – Color ______________ Amount __________________
'
'
'
'
'
Chest Symmetry
Yes
No –
Barrel
Funnel
Other ____________________________________
'
'
'
'
'
'
Night Sweats
Hemoptysis
Cyanosis – Where ________________________
Yes
No
Yes
No
Yes
No
'
Other: ____________________________________________________________________________________________________
' ' ' '
Cardiovascular:
NSF
'
'
'
Cardiac Rate or Monitor pattern: _____________________________
Regular
Irregular
Irregularly irregular
'
'
Chest Discomfort –
Where:__________________
Intensity (1 - 10)___________
Onset
_______________
Yes
No
Duration_____________________ Resolution _________________________________________
'
'
'
'
'
'
Pulse Radial (R)/(L)
Pulse Pedal (R)/(L)
JVD (R)/(L)
Yes
No
Yes
No
Yes
No
'
'
'
'
Edema – Location ______________________________________
Pitting
Non-pitting
Yes
No
'
'
Pacemaker – Date Inserted ________________ Type: ______________________ Where:
_________________________
Yes
No
'
'
Murmur ___________________________________________________________________________________________
Yes
No
' ' ' '
Skin – Extremities – Musculoskeletal:
NSF
'
'
'
'
'
Skin
Warm
Cool
Dry
Firm
Flaccid
Color: ______________________________________________ ________________________________________________________
'
'
'
'
History DVT
Homans (R)/(L)
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Extremities
Tingling
Weakness
Deformity
Contractures ________
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
Joints
Pain
Stiffness – Location: _____________________________________________
Yes
No
Yes
No
'
'
Replacement – Date ________________________ Where:
____________________________________
Yes
No
'
'
ROM
WNL
Other (location/ range): __________________________________________________________
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