Ateneo de Zamboanga University

College of Nursing

BATES ASSESSMENT TOOL

MENTAL STATUS
APPEARANCE

Grooming: ____Neat__________                      Attire: ____Casual_

Personal Hygiene: _____________Clean____________
Gait: _______Normal/straight walking pattern___ Posture: Neutral Spine   General Body
Built: weak

BEHAVIOR
Level of Consciousness:
( ) Awake (  ) Alert ( / ) Lethargic
( / ) Drowsy (  ) Stupurous or unresponsive
( /) Aware and responsive of internal and external stimuli
Facial Expression:     Tired                            Speech: __Did not answer________   
Mood:      Lethargic                                        Affect: ___Did not pay attention________

COGNITION

Oriented:     (/  )Person ( / ) Place       ( / ) Time         (  ) Confused    (  ) Sedated

      ( ) Alert (  ) Restless    ( / ) Lethargic  (  ) Comatose
Recent Memory: _______Walking into the hospital_____________
Remote Memory: ________coughing blood for weeks____________

THOUGHT PROCESS

Thought Content:     ( / ) Logical (  ) Consistent

Client’s Perceptions: (  ) Reality-base ( / ) Congruent with others
                                  (  ) Others: _______________
Suicidal Thoughts/Ideation: (   ) Present (  / ) Absent

INTEGUMENTARY SYSTEM
SKIN
INSPECTION
Color: (  ) Normal ( / ) Flushed (  ) Pale (  ) Dusky
             (  ) Cyanotic (  ) Jaundiced    (  ) Others: _________________________
Texture: Smooth Tone:                    
Lesions: ( ) Yes, site: ( / ) No
PALPATION
Moisture: _____dehydrated due to sweating_________ Temperature: __38.9C__
Turgor: _______Elastic________________
Edema: ( / ) Absent (  ) Present, site: _______________________
                                        (  ) Mild (  ) Moderate (  ) Severe
Pruritus: (  ) Yes, site: _________________ ( / ) No
Wound incision/pressure sore site: ____n/a_______  Dressing type: _____n/a_________
Odor: ( / ) None (  ) Mild (  ) Foul
Drainage/Exudates: (  ) Serous (  ) Sanguinous     (  ) Serosanguinous
Color:    (  ) Yellow (  ) Creamy (  ) Green       (  ) Beige/tan

NAILS
INSPECTION
Color: ___pinkish____ Texture: __smooth____  Configuration: rounded__ 
Symmetry: _____very symmetrical________
Cleanliness: _____very clean

HEAD AND NECK

HEAD
INSPECTION
Head Structure and symmetry: __symmetrical____
Hair Color: _____     Thinning: (  ) Yes    ( / ) No
PALPATION
Temporal Artery: ___n/a___
Cranium:___n/a___         Scalp: __n/a____
Hair Texture: __n/a____
Maxillary & Frontal Sinuses: __n/a____

EYES
INSPECTION
Conjunctiva:  R: ____    L: ____             Sclera: R: ______  L: ______
Cornea:          R: ______    L: ______    Iris:      R: ______   L:______
Ptosis:             R: ______    L: ______
Visual Fields:  R: ______    L: ______
Extraocular movements: : R: ______   L: ______
Pupil: Color:  R: _____   L: _____         Size:  R: ______   L:______
Response to Light & Accommodation: R: ______   L: ______

NOSE
INSPECTION
External Nose: ______
Nostrils: R: _________    L: _________

MOUTH
INSPECTION
Mouth & Throat Mucosa: ______ Tongue: ______
Teeth and Gums: _________________________________________ Floor of Mouth:
______ Palate: ______ Uvula: ______
Lesions and Ulcers: (  ) Yes, site: ____________ (  ) No
Salivary Glands: ______

FACE
INSPECTION
Spasms: (  ) Yes, site: __________   ( / ) No            
Tics:        (  ) Yes, site: __________ ( / ) No
Lesions:  (  ) Yes: (  ) Mild   (  ) Moderate    (  ) Severe (/  ) No              
Facial Paralysis: (  ) Yes R: _________    L: _________ (/ ) No

EARS
INSPECTION
Tympanic membrane: R: Intact ( / ) Yes    (  ) No    L: Intact ( / ) Yes    (  ) No    
Tragus of Ear: R: ______  L: ______
Canal:             R: ______  L: ______
Lesions: (  ) Yes, site: ___________    ( / ) No
Discharges: (  ) Yes, amount: ________  (  ) Left    (  ) Right   (  ) Both     ( / ) No

NECK
PALPATION
Thyroid gland size: ______ Shape: ______
Tenderness: ______ Nodules: ______
Position of Trachea: ______
Cervical Lymph Nodes: ______

RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 28bpm
Pattern:     (  ) Shallow (  ) Dyspnea (  ) Tachypnea ( / ) Shortness of Breath
Chest Symmetry:    (  ) Even ( / ) Uneven
Chest Deformities:  (  ) Scoliosis (  ) Kyphosis (  ) Kyposcoliosis (/) none
PALPATION
Chest:     (  ) Masses, site: ____________
               (  ) Bulges, site: ____________

               (  ) Muscle Tone, site: ______________

               (  ) Crepitus, site: ______________
               (  ) Areas of Tenderness, site:  ______________
               (  ) Subcutaneous Emphysema, site: ______________
Excursion:   (  ) Respiratory:       R: ______cms.      L: ______cms.      
PERCUSSION
Notes elicited: ______________ Site: __________________
AUSCULTATION
Excursion:   (  ) Diaphragmatic: R: ______cms.      L: ______cms.
Breath Sounds: 
Normal:         (  ) Bronchial   (  ) Bronchovesicular         (  ) Vesicular
Adventitious: ( / ) Crackles-Coarse, site: __Upper lobe__________ 
                       (  ) Crackles-Fine, site: ____________      
                       (  ) Stridor, site: ____________
                       (  ) Rhonchi/Gurgles, site: ____________
                       (  ) Wheezes, site: ____________
                       (  ) Pleural Friction Rub, site: ____________
Other Abnormal Findings: Voice Resonance:
(  ) Bronchophony (  ) Egophony (  ) Whispered
(  ) Pecteriloquy (  ) Pleural Friction Rub
Chest Abnormality Location (state):
Cough:   ( / ) Yes: Type:   ( / ) Productive: blood
                                              Color of Sputum: ____Red_______   Amount: __alot_______
 (  ) Non-productive      (  ) No

CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: ______ L: ______
AUSCULTATION 
Carotid Arteries:  Bruits: ( / ) Absent (  ) Present 
Jugular Vein Distention: (  ) Yes: _______cms.      ( / ) No

HEART
INSPECTION
Point of Maximal Impulse (PMI): ______
Thrills: (  ) Present ( / ) Absent
PALPATION – Perfusion: Capillary Refill:_seconds
Murmurs: ____

PULSES
 ( ) Regular    ( / ) Strong           (  ) Irregular        (  ) Weak         (  ) Absent
 (  ) Doppler     (  ) Pacemaker
Radial: R: _______ L: _______
Pedal:  R: ____________ L: ____________
Apical: R: __101bpm_____ L: ____101bpm___
BP:       R: 90/60 mmHg L: 90/60 mmHg
GASTROINTESTINAL SYSTEM
Mouth: ______
Throat: ______

ABDOMEN
INSPECTION
Contour: __flat____
Symmetry: __symmetrical____
Gastrostomy (specify): _________N/A______________________________________
AUSCULTATION
Bowel sounds:(  ) High-pitched & Gurgling (  ) Hyperactive
(  ) Low-pitched (  ) Hypoactive
                          (  ) Tympany
Rate: _  per minute
PERCUSSION
Notes: ____________________________   Site:__________________________________
PALPATION
Abdomen:  (  ) Tender(  ) Soft/Non-Tender (  ) Firm (  ) Rigid
Mass:           ( / ) No (  ) Yes
Ascites:        ( / ) No (  ) Yes
Girth: ________________                      Inguinal Area:__________________________

MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry: __Symmetrical____ 
Deformities:______N/A__________________
Others: _________________
Peripheral pulses:
Upper Extremities:  Radial:             R: ______ L: ______
                                Ulnar:               R: ______ L: ______
                                Brachial           R: ______ L: ______
Lower Extremities: Popliteal:          R: ______ L: ______
DorsalisPedis:  R: Normal L: ______
                                Posterior Tibia:R: ______ L: ______
Edema:  (  ) Yes (  )Pitting (Grade) _________            ( / ) No
Temperature: _______________________  Site: __________________________
RANGE OF MOTION: ( / ) Yes (  ) No, area:  _________________
Deformity: ______________________________________________________________
Discrepancy in Extremity (Leg) Length (  )Yes ______________ ( / ) No
PALPATION
(  ) Musculature ________________ (  ) Body articulation_____________________
(  ) Crepitations ________________ (  ) Heat_____________________________(  ) Swelling
____________________ (  ) Tenderness_______________________
Normal ROM of extremities: ( / ) Yes (  ) No
(  ) Weakness ( Paresis) (  ) Paralysis
(  ) Contractures (  ) Joint Swelling
(  ) Pain: (  ) Bone Pain (  ) Muscle Pain (  ) Joint Pain
(  ) Others: __________________________________________
Hand Grasps: ( / ) Equal (  ) Unequal (  )Weakness (  ) R & L
Leg muscles:  ( / ) Equal (  ) Unequal (  ) Weakness (  ) R & L

NEUROLOGIC SYSTEM
 
CRANIAL NERVES
Olfactory Nerve (CN I)
Identifying different mild aromas, such as coffee, vanilla, peanut butter, and orange.
Optic Nerve (CN II)
 
Oculomotor (CN III)
 
Trochlear (CN IV)
 
Trigeminal Nerves (CN V)
 
Abducens Nerve (CN VI)
 
Facial Nerve (CN VII)
 
Acoustic Vestibulocochlear Nerve (CN VIII)
 
Glossopharyngeal Nerve (CN IX)
 
Vagus Nerve (CN X)
 
Spinal Accessory Nerve (CN XI)
 
Hypoglossal Nerve (CN XII)
 

CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: (  ) Yes (  ) No
Detect Vibration: (  ) Yes (  ) No
Discriminate Light Touch: (  ) Yes (  ) No
Detect Temperature: (  ) Yes (  ) No
Detect Stereognosis: (  ) Yes (  ) No
Detect Graphesthesia: (  ) Yes (  ) No
Two-Point Discrimination: ( ) Yes (  ) No

DEEP TENDON REFLEXES

Insertion Tendon of Biceps (C5 to C6)
______________________________________________________________
Insertion Tendon of Triceps (C7 to C8)
______________________________________________________________
Insertion Tendon of Brachioradialis (C5 to C6)
_____________________________________________________________
Insertion Tendon of Quadriceps/Knee Jerk (L2 to L4)
_____________________________________________________________
Insertion Tendon of Achilles/Ankle Jerk (S1 to S2)
 _____________________________________________________________________
_

SUPERFICIAL REFLEXES

Abdominal (upper T8 to T10, lower T10 to T12)

______________________________________________________________
Cremasteric Reflex (L1 to L2)
______________________________________________________________
Plantar Reflex
______________________________________________________________

GENITOURINARY
PERIANAL REGION
INSPECTION

(  ) Hemorrhoids: (  ) Bleeding ( / ) Not

(  ) Fissures (  ) Scars (  ) Lesions (  ) Rectal Prolapse
(  ) Fistula (  ) Discharge (  ) Blood in stool

PALPATION
(  ) Rectal Masses

MALE GENITALIA
INSPECTION
Hair Distribution:
________Symmetrical_____________________________________________
Penis: Dorsal Vein: ( / ) Yes   (  ) No
Urethral Meatus Appearance: _________________________________________
Bumps:   (  ) Yes, site: ___________  ( / ) No
             Blisters:    (  ) Yes, site: ___________  (/  ) No
Lesions:    (  ) Yes, site: ___________  (  /) No
             Redness:  (  ) Yes, site: ___________  ( / ) No
Scrotum: R: ____________ L: ____________
Urine:   Color: _____Yellowish_________________         Character: _____N/A________
  Frequency per day: ____N/A_______     Amount: ________N/A_____________
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): ______________________                
Others (specify): _________________________

FEMALE GENITALIA
INSPECTION
Mons Pubis: Labia Majora:
Labia Minora: Clitoris:
Vagina: Urinary Meatus:
Skene’s and Bartholin’s Glands:
Urine: Color: ____________        Character: ______
Frequency per day: ___________       Amount: ___________________
(  ) Anuria (  ) Hematuria   (  ) Dysuria (  ) Incontinence
(  ) Catheter (Type): _________________                Other:____________________
LMP: ( ) Vaginal Discharges: __________________________________
Menstrual Problems:
(  ) Amenorrhea (  ) Dysmenorrhea (  ) Menorrhagia
(  ) Metrorrhagia (  ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche: Length of Cycle:
Menopause: ___________________Last Pap Smear: ____________________
Monthly Breast Self-Examination ( ) Yes(  ) No
Method of Birth Control: _____________________________
Obstetrical History: AOG
POP:  ______ Weight:  ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: ___________________
Urine Test Result: ___________________ Pregnancy Test: 
(  ) Albumin _______ (  ) Sugar ________
(  ) Protein   _______ (  ) RBC    ________                (  ) Pus ________
Bleeding:     (  ) Yes, amount: ___________ (  ) No    
Uterine Discharges:
Rubra:  Color ________________         Odor________         
                Serosa:  Color_______ Amount________ Odor_________
                Alba:     Color_______ Amount________ Odor_________

PSYCHOSOCIAL
Recent Stress: _________Present health condition___________________
Coping Mechanism: __________________________________________________
Support System: ______Family_______________________________________
Calm:            (  ) Yes____________________  ( / ) No______________________
Anxious:        ( / ) Yes____________________  (  ) No______________________
Angry:           (  ) Yes____________________  ( /) No______________________
Withdrawn:   (  ) Yes____________________  ( / ) No______________________
Irritable:        (  ) Yes____________________  ( /  ) No______________________
Fearful:         ( / ) Yes____________________  (  ) No______________________
Religion: Roman Catholic                                       Restrictions: _________________
Feeling of Helplessness:      (  ) Yes        ( / ) No
Feeling of Hopelessness:     (  ) Yes        ( / ) No
Feeling of Powerlessness:   (  ) Yes        ( /  ) No
Tobacco Use: (  ) Yes____________________  ( / ) No______________________
Alcohol Use:   (  ) Yes____________________  ( / ) No______________________
Drug Use:       (  ) Yes____________________  ( / ) No______________________

NUTRITION
General Appearance:     ( / ) Well Nourished       (  ) Malnourished
                                        (  ) Emaciated            (  ) Other
Body Built: ____Normal_______   Weight: _52kg___      Height: __N/a_
Diet: _______________________________________________________        Meal
Pattern:__________________________
                      ( / ) Feeds Self          (  ) Assist           (  ) Total Feed

Mastication/Swallowing Problem       (  ) Yes_________ ( / ) No_________

Dentures:   (  ) Yes                ( / ) No
Appetite:   (  ) Increased      ( / ) Decreased    (  ) Unusual 
Decreased Taste Sensation: (  ) Yes             ( / ) No
Nausea:     (  ) Yes                ( / ) No   
Stool frequency: __N/A___                  Characteristics: __N/A__
Last Bowel Movement: ____N/A________
NGT/ Gastrostomy:____N/A______________

VENOUS ACCESS RECORD

Date Gauge (color)/ Number of Date
# Site Fluid Reason
Inserted Drops Removed

PAIN ASSESSMENT
Location of pain: _____N/A_______                             Frequency: _____N/A___________
Intensity Pain Scale(0-10): N/A                            Quality: __N/A___
Onset: (When did your pain started?) ____N/A______
Duration:_______2 weeks___________ Body Reaction: Elevated temperature, sweating,
lethargic____
Alleviating Factors: ________N/A_______________________________________________
Precipitating factors:________N/A_________________________________________
Special Assessment Devices
(  ) Wheelchair (  ) Contacts (  ) Venous Access device
(  ) Braces (  ) Hearing aid (  ) Epidural catheter
(  ) Cane/ Crutches (  ) Prosthesis (  ) Walker
(  ) Glasses
Others:____________________________________________________________

SELF-CARE
Need Assist With:
(  ) Ambulating (  ) Elimination
(  ) Bed Mobility ( / ) Meals
( / ) Hygiene (  ) Dressing
 PATIENT EDUCATION
( ) Safety / Restraint Use     (  ) Signs & Symptoms to Report
(  ) Ordered Therapies     (  ) Lifestyle Change
(  ) Diagnosis / Disease     (  ) Rehabilitation Measures
(  ) Pain Management     ( / ) Hygiene / Self care
(  ) Hospital Referrals     ( / ) Diet or Nutrition
(  ) Community Referral        (  ) Mobility / Ambulation
( / ) Medication

Specify Plan of Care Intended:

Paracetamol 500mg/tab every 4 hours PRN for fever, tranexamic Acid 100mg/kg IVT every 6
hours PRN for hemoptysis and myrin P forte 3 tablets OD 1 hour before breakfast
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________