physical assessment tool

Mindanao State UniversityCOLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student _____________________________________ Clinical Instructor ____________________________________

Area of Assignment Date Submitted _____________________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name Address Age

Sex Religion Civil Status Occupation

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco 2. Alcohol 3. OTC-drugs/ non-prescription drugs

A. CHIEF COMPLAINTS

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational responsibilities, affected diagnoses}.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth and developmental history, nutrition- for pedia)

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases: Hypercholesterolemia Diabetes Kidney Disease Heart Diseases Tuberculosis Hypertension

Alcoholism Cancer Drug Addiction Asthma Hepatitis A Epilepsy

B Mental Illness C Rheuma/Arthritis

Others (pls. specify) Others (pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION

REVIEW OF SYSTEMS

Name Date Vital Signs: Height

Temperature Weight Pulse Observation ____________________________________ Respiration Blood Pressure

1.GENERAL

2. HEENT

3. INTEGUMENTARY

DRUG STUDY

4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10. ENDOCRINE

BRAND NAME GENERIC NAME CLASSIFICATION

Prescribed and Recommended dosage,

frequency, route of administration

Mechanism Of

Action Indication Contraindication Adverse Reaction Nursing Responsibilities

NURSING ASSESSMENT II

Name Age ____ Sex ____ Chief Complaint _________________________________ Impression/Diagnosis _____________ Date/Time of Admission Inclusive Dates of Care _ _ Diet: _____________________ Allergies _______ __ Type of Operation (if any) __________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

1.ACTIVITIES- REST

a. Activities

b. Rest

c. Sleeping pattern

2.NUTRITIONAL- METABOLIC

a. Typical intake(food, fluid)

b. Diet

c. Diet restrictions

d. Weight

e. Medications/supplement food

3. ELIMINATION

a. Urine (frequency, color, transparency)

b. Bowel (frequency, color, consistency)

4. EGO INTEGRITY

a. Perception of self

b. Coping Mechanism

c. Support System

d. Mood/Affect

5. NEURO-SENSORY

a. Mental state

b. Condition of five senses:

(sight, hearing, smell, taste,

touch)

.

6. OXYGENATION

a. Vital signs

Temperature

Respiratory rate

Heart rate

Blood pressure

b. Lung sounds

c. History of Respiratory

Problems

7. PAIN-COMFORT

a. Pain (location, onset, character, intensity,

duration, associated symptoms, aggravation)

b. Comfort measures/Alleviation

c. Medications

8. HYGIENE AND ACTIVITIES OF DAILY LIVING

9. SEXUALITY

a. female (menarche, menstrual cycle, civil status, number of children, reproductive status)

b. male (circumcision, civil status, number of children)

LABORATORY AND DIAGNOSTIC PROCEDURES

DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

NURSING MANAGEMENT

SURGICAL MANAGEMENT

DISCHARGE PLAN

NAME ______________________________________________ DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION