RLE FORM 001

Cebu Normal University

College of Nursing
Cebu City

NURSING ADMISSION AND ASSESSMENT

Name of Student: ____________________________________________ Clinical Assignment:_____________

Name of Clinical Instructor: ____________________________________ Inclusive dates:_________________

A. General Admission Information

Name of Patient: __________________________________________________ Age: ______ Sex: _________
Date________________ Time: _________ Mode: __________________ Allergies: _____________________
TPR_______ BP: ________ HT: ________ WT: _________ Diet: ___________________________________
Sleeping Habits: __________________________________ CBC: Yes____ No____ Urinalysis: Yes___ No___
Property:
Glasses _____
Contact Lenses ______
Dentures _______
Prosthesis _____
Ring ______
Watch Money ______
Other _______________________________________________________________________
Valuable to Business Office: _____________________________________________________
Physical Appearance:______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Behavior Exhibited: _______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Content of Conversation: ___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

__________________________
Physician In-charge

B. Admission Interview
1. Patients perception of reason for admission:______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. Patients symptoms as he/she sees them:_________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

3. Problems in daily living created by symptoms (as patient views them)

__________________________________________________________________________________
__________________________________________________________________________________
4. Past Medical History (especially as it relates to P.I.)
a. Medical__________________________________________________________________________
b. Surgical_________________________________________________________________________
c. Allergies_________________________________________________________________________
d. Medication_______________________________________________________________________
e. Traumatic Injuries__________________________________________________________________
f. Orthopedic________________________________________________________________________
g. Other (psychiatric, etc.)_____________________________________________________________
5. Habits:
a. Smoking____________________ Alcohol_______________________ Drugs__________________
b. Eating___________________________________________________________________________
c. Social Activity_________________________ Physical Execise______________________________
d. Rest/Sleeping_____________________________________________________________________
________________________________________________________________________________
e. Sexual__________________________________________________________________________
________________________________________________________________________________
f. Elimination_______________________________________________________________________
6. Social Economic History:
a. Native Language__________________________________________________________________
b. Education________________________________________________________________________
c. Occupation_______________________________________________________________________
d. Financial Status (what is the impact of current hospitalization)
________________________________________________________________________________
________________________________________________________________________________
e. Civil Status:

Married______

Single______

Divorced______

Widow______

f. Living Situation:

Lives alone_______________________________________________________
Living with others (specify)___________________________________________

7. Family History : Heart Disease, Cancer, TB, Mental Illness and others (specify)
__________________________________________________________________________________
__________________________________________________________________________________

8. Primary Physicians Admitting Diagnosis (indicate P = Probable and C = Confirmed)

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

C. Nursing Review of Systems (circle the appropriate symptoms)

1. EENT:

Headaches
Eye pain
Sinus pain
Sore Throat

Hearing Loss
Eye Infection
Facial pain
Nasal-Tracheal pain

Visions
Diplopia
Blurring
Epistaxis
Bleeding gums
Dentures
Other______________________________

2. CARDIO-RESPIRATORY: Chest pain (site) _____________________________________________

Chest pain with exertion Dyspnea on exertion
Nocturnal dyspnea
Edema
Hypertension
Palpitation
Known murmur
Cough Sputum
Hemoptysis
Pleuritic pain
Diaphoresis
Last X-ray_______________________________ EKG____________________________________
3. GASTRO-INTESTINAL:
Thirst
Heartburn
Abdominal pain
Hemorrhoids Hernia

Nausea
Vomiting
Hematemesis
Difficulty Swallowing
Flatulence
Constipation
Jaundice
Diarrhea
Tarry stool
Other: _____________________________________________________

4. GENITO-URINARY:
Dysuria
Polyuria
Nocturia
Burning

Frequency
Hematuria

Urgency
Stones

a. Female Genital Tract Menstrual History: Age of onset__________________________________

Frequency____________ Regularity_______________ Duration___________________________
Date last period___________________ Post menopausal bleeding_________________________
Age__________ Symptoms________________________________________________________
b. G______________________ P______________________ Ab____________________________
c. Male Genital Tract:
Penile discharges
Lesions
Pain
Testicular swelling
Other______________________________________________________
Last Serology Test___________________________________________
5. MUSCULO-SKELETAL:
Muscle pain
Extremity pain
Joint pain
Back pain
Joint swelling
Neck pain
Stiffness
Limited motion
Redness
Sprains
Deformity
Other___________________________________________________________________________
X-rays___________________________________________________________________________
6. NERVOUS:
Convulsions
Syncope
Dizziness
Vertigo
Tremor
Speech Difficulty
Limp paralysis
Peresthesia
Muscle atrophy
Muscle tenderness
EEG____________________________________________________________________________
Other___________________________________________________________________________
7. ENDOCRINE:
Goiter
Exopthalmos
Change in body contour

Tremor
Voice change
Infertility

Heat or Cold intolerance

Polydipsia
Other______________________________

9. EMOTIONAL:
Anxiety
Depression
Fear
Anger
Frustration
Other(specify)________________________
Notes: ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

D. Nursing Observation
1. HEENT
a. Symmetry____________________________________________________________________
b. Eyes and Pupils_______________________________________________________________
c. Ears________________________________________________________________________
d. Mouth and Throat______________________________________________________________
e. Lymph nodes_________________________________________________________________
2. RESPIRATORY
a. Death and Rate_______________________________________________________________
b. Breath sounds________________________________________________________________
c. Chest expansion_______________________________________________________________
3. CARDIO-VASCULAR
a. Blood Pressure (R)__________

(L)_________

Lying________

Standing_____

4. CHEST
a. Anterior chest_________________________________________________________________
b. Posterior chest________________________________________________________________
c. Breasts______________________________________________________________________
1. Breast and Axillae___________________________________________________________
2. Anterior Thorax_____________________________________________________________
5. GASTRO-INTESTINAL
a. Bowel sounds_________________________________________________________________
b. Tenderness or rigidity___________________________________________________________
6. URINARY
a. Bladder______________________________________________________________________
7. SKELETAL
a. Joints_______________________________________________________________________
b. Range of Motion_______________________________________________________________
8. NEURO
a. Motor Function
1. Facial_____________________________________________________________________
2. Extremities_________________________________________________________________
b. Sensory Function (equal or not equal)______________________________________________
c. Equilibrium
1. Balance____________________________________________________________________
2. Finger to nose_______________________________________________________________
d. Reflexes(equal or not equal)
1. Knees______________________________________Arms___________________________
9. CRANIAL NERVE FUNCTION
a. Olfactory nerve: (sensory)
1. Sense of smell(coffee, vanilla, etc.)
1.1 Anosmia_______________________________________________________________
1.2 Hyperosmia_____________________________________________________________
b. Optic nerve: (sensory)
1. Sense of vision (snellens chart, newspaper)
1.1 Myopia________________________________________________________________
1.2 Hyperopia______________________________________________________________

c. Oculomotor:(motor)
1. Extra-ocular movements/Pupil reaction to light
1.1 Right eye______________________________ 1.2

Left eye_______________________

d. Trochlear:(motor)
1. Assess direction of gaze, upward and downward movement of eyeball
____________________________________________________________________________
e. Trigeminal nerve: (Sensory and motor)
1. Presence of corneal reflexes_____________________________________________________
1.1 Right eye______________________________ 1.2 Left eye_______________________
2. Ability to clench teeth___________________________________________________________
f.

Abducens:(motor)
1. Assess direction of gaze, lateral movement of eyeballs
1.1

Right eye_____________________________ 1.2

Left eye_______________________

g. Facial: (Sensory and motor)

1. Sense of taste: Using back of tongue
1.1

Salty_________________________________ 1.2

Sweet________________________

2. Facial expression:
2.1
2.3

Smile_________________________________ 2.2
Frown_________________________________ 2.4

Puff out cheeks_________________

Raise lower eyebrows___________

h. Auditory nerve:(motor)
1. Sense of hearing
1.1 Right ear______________________________ 1.2

Left ear_______________________

i.

Glossopharyngeal:(Sensory and motor)

1. Sense of taste: Using back of tongue
1.1 Sour_________________________________ 1.2 Sweet________________________
2. Ability to swallow (Use tongue blade to elicit gag reflex)
____________________________________________________________________________

j.

Vagus:( Sensory and motor)

1. Hoarseness of voice____________________________________________________________
2. Sensation of pharynx___________________________________________________________
Let patient say ah and observe(movement of palate and pharynx)

k. Spinal accessory:(motor)
1. Movement of:
1.1 Head_________________________________ 1.2
l.

Shoulder______________________

Hypoglossal:(motor)
1. Able to stick tongue to midline____________________________________________________

10. EMOTIONAL
a. Communication________________________________________________________________
b. Mood/Effect__________________________________________________________________
c. Behavior_____________________________________________________________________

Knowledge of Illness
1. Learning Limitations_______________________________________________________________
_______________________________________________________________________________
2. Learning needs___________________________________________________________________
_______________________________________________________________________________

F. Nursing Impressions
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

G. Nursing Problems(in priority)

1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________

H. Discharge Planning
1. Probable Date_________________________________________________________________
2. Destination___________________________________________________________________
3. Transportation________________________________________________________________
4. Agencies and Equipment Involved_________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. Diet_________________________________________________________________________
6. Medications__________________________________________________________________
____________________________________________________________________________
7. Persons responsible for patient___________________________________________________
8. Family conference_____________________________________________________________
9. Anticipated problems___________________________________________________________
10. Home visit____________________________________________________________________

Rating Scale:

when the item gives much more than what is expected

when the item gives more than what is expected

when the item gives what is expected

when the item gives less than what is expected

when the item gives much less than what is expected

_________________________________
Signature of Student

________________________________
Signature of Clinical Instructor