Community College of Baltimore County
Concept Based Assessment
Student name:
Date:
Client Initials:
Client Age:
Allergies:
Code Status:
Safety Precautions:
Snapshot Assessment (General
Appearance, General Survey):
_____Appears Stated Age
_____Level of Consciousness
_____Skin Color
_____Posture and Position
_____NO Obvious Physical
Deformities
_____No Obvious Signs of Distress
_____Facial Expression
_____Mood and Affect
_____Speech
_____Hearing
_____Hygiene
Abnormal Findings:
Comfort:
_____Performs adequate self-care
for personal hygiene
_____ Reports adequate sleep
Abnormal Findings:
Pain Scale Score (0-10):
____________
If pain present, indicate location,
onset, duration, quality, intensity
and pattern.
Neural Regulation/Cognition:
_____alert & oriented X3
_____face symmetrical
_____PERRLA
_____eyes open spontaneously
_____follows commands
_____gross motor intact
_____sensation intact
_____memory intact
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Abnormal Findings:
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Sensory Perception:
_____eyes and ears without masses,
lesions, tenderness, or discharge
_____no issues noted with visual acuity
_____extraocular muscle function
intact
_____no issues noted with hearing
acuity
Abnormal Findings:
Hearing aid(s): Yes or No (Circle one)
Glasses or Contact Lenses: Yes or No
(Circle one)
Communication:
_____communicates in age-appropriate
manner
_____expressive language intact
_____ receptive language intact
Perfusion:
_____apical pulse regular
_____S1 and S2 present
_____heart rate 60 – 100
_____SBP <120/80, and >90/60
_____peripheral pulses strong and
equal bilaterally
_____extremities warm
_____color is baseline for patient
_____cap refill < 3 seconds
_____ JVD absent
_____edema absent
_____murmur absent
Abnormal Findings:
Abnormal Findings:
BP: ________ P:_______
Gas Exchange:
_____respirations regular and
unlabored
_____absence of cough
_____resting rate 12-20
_____breath sounds clear and equal
bilaterally
_____symmetrical rise and fall of chest
_____no shortness of breath at rest
_____no dyspnea on exertion
_____Pulse Ox within normal limits
_____lips and nail beds pink
Abnormal Findings:
Respiratory Rate: ________
Pulse Ox: ________
Oxygen type and
flow:_____________________
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Infection and Tissue Integrity:
_____skin warm, dry, and intact
_____skin without bruising, petechia,
or discolored areas
_____skin without rash or irritation
_____ Temp 96.8 to 100.4 F
_____no procedural sites (e.g., drains,
chest tubes, IV’s)
_____no dressings
_____no wounds and/or pressure sores
_____no Incisions
Abnormal Findings:
Braden Score: _________
Transmission-based precautions:
_________________
Temperature: _________
Location: A, O, R, T (circle one)
Nutrition:
_____no loose teeth
_____able to feed self
_____able to swallow
_____no nausea/vomiting
_____appetite normal
_____oral mucosa moist and intact
_____bowel sounds present in 4
quadrants
_____abdomen soft, non-tender, nondistended
_____no apparent masses
_____percussion (tympany vs. dullness)
Abnormal Findings:
Dentures: Partial or Full (Circle One)
Previous Weight: __________
Today’s weight: ____________
Height: __________________
BMI: __________________
Diet order: ___________________
% meal eaten: _________________
TPN Y/N & rate ____________
Enteral Tube - Y/N & type________
Enteral feeding type and rate:
____________________________
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Elimination:
_____no diarrhea or constipation
_____BM’s regular in pattern,
consistency, and color
_____continent of stool
_____no ostomy
_____voids without difficulty
_____no dysuria or frequency
_____urine output > 30 ml/hour
_____urine clear, yellow, with no odor
_____continent of urine
Abnormal Findings:
Urine Output: _______________ml
Other output: ________________
Foley: Yes or No (Circle one)
Last BM: _____________________
Mobility:
_____no physical limitations
_____functional range of motion
_____no muscle atrophy, weakness, or
contractures
_____normal spinal curvature
_____demonstrates coordination and
balance
Abnormal Findings:
Current Activity order: ____________
Stress and Coping, Culture:
_____compliant with care
_____adequate coping
_____social support system in place
_____cultural needs met
_____spiritual needs met
Abnormal Findings:
Fluid and Electrolytes:
_____ If IV present- no signs of
infiltration, phlebitis, leaking
_____Intake and Output balanced
_____minimal weight fluctuation
_____no evidence of fluid volume
deficit or excess
Abnormal Findings:
IV Type: Peripheral or Central Line
(Circle One)
Location: _________________
Date IV inserted per dressing:
___________
Gauge: ___________
IV fluid Solution: _______________
Rate: __________
Metabolism:
Abnormal Findings:
Glucose (Fingerstick): ____________
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