physical assessment tool
DESCRIPTION
Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student _____________________________________ Area of Assignment Clinical Instructor ____________________________________ Date Submitted _____________________________________ NURSING ASSESSMENT I PATIENT’S PROFILE Name Sex Religion Address Civil Status Occupation AgeHEALTH HABITS Frequency 1. Tobacco 2. Alcohol 3. OTC-drugs/ non-prescription drugs Amount Period/DurationA. CHIEF COMPLAINTSB. HISTORY OF PRESENT ILLNESSTRANSCRIPT
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