Nursing Assessment Form

Nursing assessment form is a pre-developed layout used by the nurses for gathering the information about their patients and what kind of nursing care do they require. This kind of an assessment form has to be designed effectively with enormous provision for identifying the health status of the patients and assessing the type of nursing facility they requires.

Sample Nursing Assessment Form

Patient’s Name: ___________________________________      D.O.B: ________________

Gender:         Male         Female

Reason of Assessment: _____________________________________________________

Assessment Conducted by: ___________________________

Department: ___________________________________

i)                    Health History/Overview of General Health Status:

____________________________________________________________________________________________________________________________________________________________

ii)                  Type and Treatment Taken for Major Illness (If any):                                [ ] Tick, if none

____________________________________________________________________________________________________________________________________________________________

iii)                Hospitalizations(Duration and details of diagnoses, if any):                      [ ] Tick, if none

____________________________________________________________________________________________________________________________________________________________

iv)  Major Injuries (Type and Treatment taken, if any):                                   [ ] Tick, if none

____________________________________________________________________________________________________________________________________________________________

iv)                Immunity:

  1. Current immunizations taken: [ ] Influenza     [ ]Tetanus  [ ]PPD   [ ]Pneumonia
  2. Hepatitis surface and core antigen, antibodies tested on ____________, result __________________.
  3. HIV tested: [ ] yes  [ ]No
  4. Exhibits (if any): [ ] weight loss, [ ] productive cough, [ ] weakness, [ ] night sweats, [ ] loss of appetite, [ ] low grade fever.

v)                  Overall body review and physical examinations

  1. a.      Skin:

[ ] Clear and Healthy Skin Observed   [ ] Presence of lesions, rashes, wound and bruises found [ ] lice/infection

Type: Oily/ Normal/ Dry

Comments: ____________________________________________________________________________________________________________________________________________________________

  1. b.      Stoma:

[ ] Redness, [ ] Chronic redness, [ ] Drainage, [ ] Chronic drainage, [ ] prolapsed    [ ] healthy and normal, no damage observed.

Comments: ____________________________________________________________________________________________________________________________________________________________

  1. c.       Toenails and Fingernails:

[ ] No problems and damages are assessed [ ] Fungal Problem Observed [ ] Inflammation around nails skin [ ] irregularities in the skin around nails

Comments: ____________________________________________________________________________________________________________________________________________________________

Assessment Result: _______________________________________________________

Signature of the Nurse-in-charge ___________________________

Date: _________________

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