MINDANAO INSTITUTE OF HEALTHCARE PROFESSIONALS, INC.
Marawi City
PHYSICAL ASSESSMENT
NAME OF STUDENT: _____ SCORE: ________________
AREA OF ASSIGNMENT: ___ CLINICAL INSTRUCTOR:
DATE OF SUBMISSION: _______________________
PATIENT’S PROFILE
Name: Age: Sex: Status:
Address: Religion:
HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco
2. Alcohol
3. OTC drugs/non-prescription drugs
A. Chief Complaints:
B. History of Present Illness: (location, onset, intensity, duration, aggravation and alleviation, associates symptoms, previous treatment and result, social and
vocation, responsibilities and diagnosis.)
C. History of Past Illness: (previous hospitalization, injuries, procedures, infectious diseases, immunization/health maintenance, major illness, allergies,
medications, habits, birth and developmental history, pattern of sleep, exercise and nutrition.)
D. Family History with Genogram
Legend:
Male
Female
Patient
Acquired diseases: Heredo – familial Diseases:
Hypercholesterolemia Diabetes
Kidney Disease Heart Disease
Tuberculosis Hypertension
Alcoholism Stroke
Drug Addiction Cancer
Hepatitis A Arthritis
B Rheumatism
C Allergies
Others (Pls. Specify) Asthma
Epilepsy
Mental Illness
Others (Pls. Specify)
E. Patient Perception of
Present Illness:
Hospital Environment
F. Summary of Interaction
REVIEW OF SYSTEM
Name of Patient: Date:
Vital Signs:
Temperature: Height:
Pulse: Weight:
Respiration: Blood Pressure:
Observation:
1. GENERAL
2. HEENT H-
E-
E-
N-
T-
3. Integumentary
4. Respiratory
5. Cardiovascular
6. Digestive
7. Excretory
8. Musculoskeletal
9. Nervous
10. Endocrine
NURSING ASSESSMENT II
Name of Patient: Age:
Chief Complaint: Sex:
Impression / Diagnosis: Inclusive Dates of Care:
Diet: Allergies:
Type of Operation:
Normal Pattern Before Hospitalization Clinical Appraisal
Initial Day 1 Day 2
1. Activities – Rest .
a. Activities
b. Rest
c. Sleeping Pattern
2. Nutritional – Metabolic
a. Typical Intake
(food or fluid)
b. Diet
c. Diet restriction
d. Weight
e. Medication/Supplement food
Normal Pattern Before Hospitalization Clinical Appraisal
Initial Day 1 Day 2
3. Elimination
a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
transparency)
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 5 Senses:
(sight, hearing, smell,
taste, touch)
Normal Pattern Before Hospitalization Clinical Appraisal
Initial Day 1 Day 2
6. Oxygenated and Vital Signs
a. Respiratory Rate
b. Pulse Rate
c. Temperature
d. Blood Pressure
e. Lung Sounds
f. History of Respiratory Problems
7. Pain Comfort
a. Pain (location, onset, intensity,
duration, associated symptoms,
aggravation)
b. Comfort Measures / Alleviation
c. Medication
Normal Pattern Before Hospitalization Clinical Appraisal
Initial Day 1 Day 2
8. Hygiene & Activities of Daily
Living
9. Sexually
a. Female (menarche, menstrual
cycle, civil status, number of
children, reproductive organ.
b. Male (circumcision, civil status,
number of children)
DRUG STUDY
Prescribed,
Generic Name Recommended,
Brand Name Dosage, Frequency, Mechanism of Indications Contraindications Adverse Effect Nursing
Classification & Route of Action Responsibilities
Administration
LABORATORY AND DIAGNOSTIC PROCEDURES
Name of Procedure Result Normal Value Nursing Implication
Hematology
WBC
RBC
Hematocrit
Hemoglobin
Platelets
Segmenter
Lymphocyte
Monocyte
Eusinophils
Urinalysis
Color
Transparency
Pus Cells
RBC
Epithelial Cells
Bacteria
LABORATORY AND DIAGNOSTIC PROCEDURES
Name of Procedure Result Normal Value Nursing Implication
LABORATORY AND DIAGNOSTIC PROCEDURES
Name of Procedure Result Normal Value Nursing Implication
SUMMARY OF INTRAVENOUS FLUID
Date / Time Started Intravenous Fluids & Volume Drop Rate Number of Hours Date / Time
SUMMARY OF MEDICATION
Date / Time Medication Remarks
NURSING CARE PLAN
CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
DIAGRAM OF PATHOPHYSIOLOGY
(Actual on Patient’s Case)
MEDICAL MANAGEMENT
IDEAL:
ACTUAL MEDICAL MANAGEMENT
NURSING MANAGEMENT
DISCHARGE PLAN
Patients Name: Date of Discharge:
Condition upon Discharge: Nature: Home per Request ( ) Discharge Against Medical Advice ( )
MGH ( )
1. Medication
2. Exercise
3. Diet
4. Health Teaching
5. Schedule for next visit
