Nursing Admission Assessment Template Page 4
ADVERTISEMENT
1
2
3
4
5' ' ' '
Physical Findings:
NSF
Describe and graph all abnormalities by number:
1.
Bruises
2.
Incisions
3.
Lacerations
4.
Rashes
5.
Decubitus
6.
Dryness
7.
Scars
8.
Lesions
9.
Abnormal color
10.
Other : ____________________________________
11.
Tattoos
12.
Body Piercing
13.
Skin Tear/ Duoderm/Op-Site
' ' ' '
Gastrointestinal:
NSF
Bowel sounds
'
'
'
Appetite
Good
Poor
Recent change _____________________________
Last BM
Date: _________ Color _______________________ Frequency: ___________________
'
'
Laxative use – Type __________ Frequency ___________________ How long ___________________
Yes
No
'
'
'
'
'
'
'
'
Constipation
Diarrhea
Nausea
Vomiting
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Distention
Hemorrhoids
Heartburn
Flatus
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Colostomy
Ileostomy
Pain
Rectal Bleeding
Yes
No
Yes
No
Yes
No
Yes
No
'
'
Weight gain/loss – Reason: _______________________________________________________
Yes
No
' ' ' '
Genitourinary:
NSF
Color of urine _________________ '
'
Odor _________________________________________
Yes
No
'
'
'
'
'
'
Frequency
Flank pain
Burning
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Difficulty starting
Urgency
Incontinence
Itching
Yes
No
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Nocturia
Urostomy
Hx of calculi
Hx UTI
Yes
No
Yes
No
Yes
No
Yes
No
ª
'
'
Foley – Date
_____________________________________________________________________________________
Yes
No
' ' ' '
Reproductive:
NSF
FEMALE
Last PAP ____________________ '
'
LMP_______________________
G _____ P _____ A ______
Birth control
Yes
No
'
'
'
'
Hormone replacement '
'
Menopausal – How long? __________________________
Lesions
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
'
Vaginal discharge
Itching
Dysmenorrhea
Amenorrhea
Yes
No
Yes
No
Yes
No
Yes
No
'
'
Hx STD exposure
Yes
No
'
'
'
'
Breast
Do SBE Monthly?
Lumps
Last Dr. exam ________________ Last mammogram ______
Yes
No
Yes
No
'
'
'
'
'
'
Breast feeding
Nipple discharge
Family Hx
Yes
No
Yes
No
Yes
No
'
'
'
'
'
'
'
'
Dimpling
Symmetry
Nipple inversion
Pain
Yes
No
Yes
No
Yes
No
Yes
No
MALE
'
'
Penile discharge '
'
Last prostate exam _________________ Last PSA _____________________
Hernias
Yes
No
Yes
No
'
'
'
'
'
'
Sores
Testicular lumps
Hx STD exposure
Yes
No
Yes
No
Yes
No
Hygiene _____________________________________________________________________________________________________
'
'
'
'
'
'
'
'
Breast
Pain
Lumps
Swelling
Nipple discharge
Yes
No
Yes
No
Yes
No
Yes
No
' ' ' '
Hematological:
NSF
'
'
'
'
'
'
'
'
Bruising
Anemia - Hx
Anemia - Current
Blood Transfusion - Hx
Yes
No
Yes
No
Yes
No
Yes
No
'
'
Anticoagulant use
Yes
No
Nurse doing Assessment
Date:
Page 4 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical