Nurse's Pocket Guide

ADULT MEDICAL/SURGICAL
ASSESSMENT TOOL
General Information
Name: _____________________ Age: ______ DOB: ________
Gender:
Race:
Admission: Date: ______ Time: ________ From: __________
Reason for this visit (primary concern): _____
Cultural concerns (relating to healthcare decisions, religious
concerns, pain, childbirth, family involvement, communication,
etc): ______
Source of information: ______ Reliability (1–4 with 4 very
reliable): ________________________________________
Activity/Rest
SUBJECTIVE (REPORTS)
Occupation: Able to participate in usual
activities/hobbies: __________________________________
Leisure time/diversional activities: _______________________
Ambulatory: _____ Gait (describe): ____________________
Activity level (sedentary to very active): _______________
Daily exercise/type: ________________________________
Muscle mass/tone/strength (e.g., normal, increased, decreased):
__________________________________________________
History of problems/limitations imposed by condition (e.g.,
immobility, can’t transfer, weakness, breathlessness):
__________________________________________________
Feelings (e.g., exhaustion, restlessness, can’t concentrate, dissatisfaction):
________________________________________
Developmental factors (e.g., delayed/age): _________________
Sleep: Hours: _________ Naps: ________________________
Insomnia: _____ Related to: _____________ Difficulty falling
asleep: ___________________________________________
Difficulty staying asleep: Rested on awakening:
Excessive grogginess: ______________________________
Bedtime rituals: _____________________________________
Relaxation techniques: ________________________________
Sleeps on more than one pillow: ________________________
Oxygen use (type): When used:
_______________
Medications or herbals for/affecting sleep: ________________
PUTTING THEORY INTO PRACTICE 21
Sample Assessment Tool