LABORATORY EXAMINATIONS

Examination Done

Date of Examination

Results

Normal Values

Relevance/ Significance to Patient Condition

(Why was it done to the client? What is the significance of the result to the
clients condition?)

PATHOPHYSIOLOGY OF

According to the Book

As experienced by the Patient

ON-Going APPRAISAL
(Daily Condition of Patient)

Note: Start on the next day after assessment.

DRUG STUDY
Name of Drug
(Generic &
Brand Name)

Classification

Dosage

Route of
Administrat
ion

Mechanism of Action

Indication

Contraindication

Nursing Responsibilities

NURSING CARE PLAN

Cues
Subjective/
Objective

Nursing Diagnosis

Rationale

Nursing Objectives

Nursing Interventions

Rationale

Expected Outcome/
Evaluation

ADMISSION DATA:
Name:_________________________________
Arrived via:

Wheelchair

Date& Time of Admission:_______________________

Stretcher

Weight:____________ Height:______________

Ambulatory
Blood Pressure: R____________ L____________

Temperature: ____________________ Pulse:__________________ Respiration:__________________

Source Providing Information:

Patient

Others __________________________________

Reason for Admission(Include Onset, Duration, Patients Perception):

_____________________________________________________________________________________
_____________________________________________________________________________________
Impression/ Tentative Diagnosis: __________________________________________________________
Final Diagnosis: ________________________________________________________________________
Biographical Data:
Age:________ Sex:________ Marital Status:______________ Religion:__________________________
Address:______________________________________________________________________________
____________________________________________________ Tel#:___________________________
Date of Birth:_______________________________ Place of Birth: ______________________________
Educational Attainment:_________________________________ Occupation:_____________________
Dialect/ Language Spoken: _______________________________
CURRENT HEALTH STATUS:
A. Activity and Rest Pattern:
Frequency and Duration Of Exercise: _______________________________________________________
Limitation in Activity:____________________________________________________________________
Complaint of Fatigue: ___________________________________________________________________
Usual Numbers of Hours of Sleep at Night: ___________________________; at daytime: ____________
Number of Hours of sleep needed to feel rested: _____________________________________________
Any change in sleep pattern: _____________________________________________________________
Any routine preparation before going to sleep: ______________________________________________
B. Oxygenation and Circulation Pattern:
Presence of Cough: _____________________________________ Duration:________________________
Presence of Chest Pain: _____________________________ ( Location, Frequency, Duration & Type of
Pain) ________________________________________________________________________________
History of Heart Disease: _________________________________ HPN: _________________________
History of Asthma, PTB in the Family: _____________________________________________________

Do you smoke? _________________________ Number of Cigarettes per day? ____________________

Shortness of Breath? _____________________ Coldness of extremities? _________________________
Usual or known BP:_____________________________________________________________________
C. Nutritional-Metabolic Pattern:
Food Preference: _____________________________ Food Restriction: __________________________
Any change in diet: ______________________________ Use of table salts? _______________________
Any change in appetite?_________________________________________________________________
Medication used related to diet: _________________________________________________________
Volume & Type of fluid taken per day: _____________________________________________________
Source of water supply for drinking: _______________________________________________________

D. Elimination Pattern:
a. Bladder:
Frequency & amount of urination per day: ___________________________________________
Color & Odor of urine: ____________________________________________________________
Any discomfort in urination?_______________________________________________________
Intervention done: _______________________________________________________________
b. Bowel:
Frequency of bowel elimination per day: _____________________________________________
Consistency & color of stool: _______________________________________________________
Any discomfort in bowel elimination: ________________________________________________
Intervention done: _______________________________________________________________

E. Senses:
Any difficulty in:
Seeing: _______________________________________________________________________________
Hearing: ______________________________________________________________________________
Feeling: ______________________________________________________________________________
Tasting: ______________________________________________________________________________
Smelling: _____________________________________________________________________________
How long did you had the difficulty: _______________________________________________________
How long did you manage it? ____________________________________________________________
How did this affect your lifestyle? _________________________________________________________

PHYSICAL EXAMINATION
Date Performed: ________________________________ Hospital Day # (Patient) ___________________
I.

GENERAL SURVEY : (APPEARANCE & MENTAL STATUS)

Body build, height & weight proportional to age..
Relaxed, erect posture, coordinated movement
In standing, sitting and walking.

Yes

No

Yes

No

Clean, Neat

Yes

No

Body Odor .

Yes

No

Distress Noted

Yes

No

Obvious signs of illness

Yes

NO

Cooperative .

Yes

No

Responses appropriate to situation ..

Yes

No

Understandable speech .

Yes

No

Relevant and Organized thoughts

Yes

No

II.

VITAL SIGNS, HEIGHT AND WEIGHT:

Temperature: ____________ Pulse: _________________ Respiration: _________________
Blood Pressure: L ___________ R: ___________ Height: ___________ Weight: __________

III.

INTEGUMENT
Skin:
Light Brown
Pallor

Deep Brown
Cyanosis

Jaundice

No Edema

Edema Present:_____________

Lesion Present:__________________________

Abrasion Present:___________

Excessive moisture

Excessive dryness

IV. HEAD
Hair:

Evenly distributed
Thick

Thin

No infestation
Skull:

Patches of loss hair

Silky, resilient

Brittle, dry

Lice, nits

Rounded, Symmetrical, smooth

Lack of symmetry

Absence of nodules or masses & depression

Local deformities from trauma

Face:

Symmetrical facial features

Exopthalamos

Moon face

Periorbital edema

Sunken eyes

Eyes & Vision:

Color of conjunctiva: ____________________________________________________________
Clarity of cornea: _______________________________________________________________
Color, shape & symmetry of size and pupils:__________________________________________
Pupilsreaction to accommodation:_________________________________________________
Ocular movement: ______________________________________________________________
Visual Activity: __________________________________________________________________
Ears:
Color & shape of auricle: __________________________________________________________
Position: _______________________________________________________________________
Discharge/ growth: ______________________________________________________________
Response to normal voice tones: ___________________________________________________
Nose:
Shape & Color: __________________________________________________________________
Discharges/ growth: _____________________________________________________________
Mouth & Pharynx:
Color of lips & buccal mucosa: _____________________________________________________
Color, Position & texture of tongue: _________________________________________________
Tongue movement: ______________________________ Teeth: __________________________
Color of gums: ___________________________ Color& size of tonsils: _____________________

V. Neck
Muscle size/ symmetry: ___________________________________________________________
Head movement:________________________________________________________________
Lymph nodes: __________________________________________________________________
Thyroid glands:__________________________________________________________________
VI. Upper Extremities
Skin & Nail: _____________________________________________________________________
Muscle strength & tone: __________________________________________________________
Joint range of motion: ____________________________________________________________
Brachial pulses: ____________________________ Radial pulses: _________________________

VII. Chest & Back

Skin:
Symmetry: ______________________________ Size& Shape: ___________________________
Spine Alignment: _____________________________________
Breathing Pattern: _________________________ Breath Sounds: ________________________
Respiratory muscle movement: ____________________________________________________
Heart sounds: _________________ Pitch: __________________ Intensity: _________________
Extra sounds/beats: ______________________ Murmurs: ________________________
Breast symmetry: ____________________________ Contour: ___________________________
Discharge: ______________ Lymph nodes: ______________ Growth:_______________
VIII.

Abdomen
Skin:
Symmetry: ___________________ Size: __________________ Shape: __________________

Abdominal Sounds: _________________________ Growth: __________________________

IX.

Genitals
Growth: _________________________________ Discharge: _________________________

X. Anus
Growth: _________________________________ Discharge: _________________________
XI. Lower Extremities:
Skin & toenails:______________________________________________________________
Gait & Balance: ______________________________________________________________
Joint Range of motion: ________________________________________________________
Femoral Pulses: _____________________________ Popliteal Pulses: ___________________
Posterior Tibial pulses: _______________________ Pedal Pulses: ______________________
Tendon & Plantar Reflexes: ____________________________________________________