Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING Andres Bonifacio Avenue, 9200 Iligan City, Philippines

Name: Status: Address: Religion: Occupation: Age: Sex:

HEALTH HISTORY A. Chief Complaint/s: B. Impression/Admitting Dx: C. History of Present Illness: (location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities).

D. History of Past Illness: (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition for pedia).

E.

Health Habits: Frequency Tobacco Alcohol OTC Drugs Amount Period

F.

Family History w/ Genogram: y y y y y y y ____Cancer ____DM ____Asthma ____Hypertension ____Cardiac Disease ____Mental Disorder ____Others________________

G. Patient s Perception of: y Present Illness: y Hospital Environment: H. Summary of Interaction:

REVIEW OF SYSTEM Vital Signs o Temp: ______ C Pulse: ______ bpm RR: ____ __ cpm BP: ____ __ mmHg

Height: ______ in/cm Weight:______ kgs

Observation: Pt. is____________ __________ ______ Position___________________ __________________ IVF: Where: Left: cc Reg:____

General ( )appears as stated age, ( )sexual development appropriate for age and gender, ( )alert & oriented, ( )equal fat distribution, ( )body part symmetric, equal bilateral, ( )kept hair, ( )dressed appropriately HEENT Head: ( )normocephalic, ( )mass, ( )lesions, ( )tenderness, ( )hair______, ( )even distribution, ( )equal, symmetric facial features, ( )anterior/posterior fontanels-closed, ( )facial weakness, ( )lymphadenopathy, ( )HC=___cm, ( )thyroid/neck enlargement Ears: ( )hearing impairment, ( )equal bilateral, ( )pain/inflammation/drainage, ( )uncoils after coiling Eyes:

Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING Andres Bonifacio Avenue, 9200 Iligan City, Philippines
( )far/near-sighted, ( )PERRLA, ( )nystagmus, ( )pinkish conjunctiva, ( )anicteric sclera, ( )tenderness/swelling-lacrimal ducts, ( )good focus Nose: ( )patent, ( )discharges/catarrh, ( )nasal flaring/septal deviation, ( )intact septum Throat: ( )pink lips & oral mucosa, ( )uvula-midline, ( )tonsils__, ( )intact hard & soft palate, ( )gag reflex, ( )bleeding, ( )productive/non-productive cough, ( )dentures, ( )deciduous teeth, ( )tongue______, ( )oropharynx______, ( )teeth______ Integumentary Skin: ( )color______, ( )rough/smooth, ( )firm/even/free of masses & lesions, ( )warm/cool, ( )T=_ _oC, ( )febrile/afebrile, ( )diaphoresis/dry, ( )good turgor, ( )edema, ( )rashes, ( )wounds Hair: ( )equally/even distribution, ( )lanugo, ( )seborrhea, ( )curly/straight, ( )fine/coarse Nails: ( )cut, ( )smooth/rough, ( )regular/even thickness, ( )nail base firm to palpate, ( )translucent/even nail plates, ( )pink/even nailbeds, ( )clubbing, ( )CRT_3 sec. Respiratory ( )AP<transverse, ( )trachea-midline, ( )flaring, ( ) productive/non-productive cough,( )automatic/effortless, ( )regular/even, ( )noise, ( )ECE, ( )accessory mm, ( )sternal retraction, ( )distress, ( )bronchial/bronchovesicular/vesicular, ( )resonant/tympany, ( )crackles/wheeze/rhonchi/PFR,( )crepitus/tenderness, ( )tactile fremitus, ( )RR=__cpm, ( )cyanosis/pallor Cardiovascular ( )CRT_3sec., ( )rhythmic/elastic/equal bilateral pulses, ( )brachial/radial/carotid/popliteal/dorsalis pedis, ( )radial=_ _bpm, ( )apical=_ _bpm, ( )regular/even, ( )audible S1/S2, ( )murmurs, ( )BP@__arm=__ / __mmHg Digestive ( )lips & oral mucosa_ _, ( )intact hard & soft palate, ( )tonsils__, ( )uvula-midline, ( )teeth_______, ( )gag reflex, ( )swallowing reflex, ( )salivation, ( )good appetite( )globular/soft/flat/scaphoid, ( )mass/lesion/lesions, ( )protruding umbilicus, ( )BS=____/min, ( )defecated_ _x/ _ _, ( )soft/formed/steatorrhea/melena/hematokezia Excretory ( )diaphoresis, ( )urinated_ __x/__ _____, ( )pungent, ( )transparent, ( )defecated_ x/ ( )soft/formed/steatorrhea/melena/hematokezia

_,

Musculoskeletal ( )body movements voluntary and coordinated, ( )symmetric neck/extremities/hips/spine/ facial expression, ( )capable of full ROM, ( )movement limitation, ( )mm strength_ _, ( )full ROM against gravity, ( )effusion, ( )crepitus, ( )fractures, ( )varicosities, ( )Homan s sign Nervous ( )oriented to person/place/time, ( )body movements voluntary & coordinated, ( )pace of conversation even, ( )talks fluently, ( )articulation is clear/understandable, ( )choice of words appropriate for educational level, ( )perceive pain, ( )PERRLA, ( )corneal reflex, ( )abdominal reflex, ( )gag reflex, ( )swallowing reflex, ( )patellar___, ( )Achilles , ( )brachioradialis , ( )Babinski , ( )Moro , ( )clonus __, ( )CN I, ( )CN II, ( )CN III, ( )CN IV, ( )CN V, ( )CN VI, ( )CN VII, ( )CN VIII, ( )CN IX, ( )CN X, ( )CN XI, ( )CN XII, ( )5 senses intact and functioning Endocrine ( )diaphoresis, ( )thirsty, ( )hungry, ( )heat/cold intolerance, ( )thyroid enlargement, ( )hx of endocrine disorder, ( )DM Reproductive ( )sexual development appropriate for age and gender, ( )married/single/widow, ( )circumcised, ( )child/ren___, ( )menarche , ( )menstrual cycle________days, ( )regular, ( )duration days, ( )heavy day, ( )pads , ( )G , ( )P , ( )A , ( )F , ( )P , ( )L____ NURSING ASSESSMENT II c/c: Impression/Diagnosis: Diet:

Date of Admission: Type of Operation(s): Allergies:

Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING Andres Bonifacio Avenue, 9200 Iligan City, Philippines
Before Hospitalization 1) Activity Rest a. Activities b. Sleeping pattern c. Rest Initial

2) Nutrition Metabolic a. Typical intake(food/fluid) b. Diet c. Diet restriction d. Weight e. Medication/supplement food

3) Elimination a. Urine(freq., color, transparency) b. Bowel(freq., color)

4) Ego Integrity a. Perception of self b. Coping Mechanism c. Support Mechanism d. Mood/affect

5) Neuro-Sensory a. Mental State b. Condition of 5 senses (sight, hearing, smell, taste, touch)

6) Oxygenation and Vital Signs a. RR b. PR c. HR d. BP e. Lung sounds f. Hist. of respiratory problems

7) Pain Comfort a. Pain (location, onset, intensity, duration, assoc. symptoms, aggravation) b. Comfort measures/alleviation c. Medications

8) Hygiene and ADLs

9) Sexuality a. Female (menarche, menstrual cycle, civil status, no. of children, reproductive status) b. Male (circumcision, civil status, # of children)

Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING Andres Bonifacio Avenue, 9200 Iligan City, Philippines
DATE SUMMARY OF MEDICATIONS MEDICATION

DATE & TIME STARTED

SUMMARY OF IV FLUIDS IV FLUID & VOLUME

DROP RATE

Mindanao State University Iligan Institute of Technology COLLEGE OF NURSING Andres Bonifacio Avenue, 9200 Iligan City, Philippines
PROCEDURE DIAGNOSTIC AND LABORATORY PROCEDURES NORMAL VALUE RESULTS

SURGICAL MANAGEMENT

MEDICAL MANAGEMENT

NURSING MANAGEMENT

NOTES