COMPREHENSIVE ASSESSMENT

I. Patient’s Data Name: Age: Address: Birthplace: Nationality: Birthday: Civil Status: Blood type: Diagnosis: Chief Complaint: Date & time of admission: Admitting physician:

History of past illness

History of present illness Effects of present illness to the patient/family The patient and her family expects that her illness will be cured with the help of proper therapeutic medication given by their physician and also with the help of the health care providers. REVIEW OF SYSTEMS .

foot strength and movement is normal.I. III. II. . Respiratory System  Patient’s respiratory rate is normal within 22 – 26 bpm. Central Nervous System  Patient is conscious and coherent to time. Cardiovascular System  Patients pulse rate is normal within 88 – 96 cpm. Cough noted but there is no presence of sputum. can feel dizziness when standing up. murmurs or rubs heard upon auscultation. rhythm and quality is also normal. Crackles sound heard upon auscultation. Handgrips. Point of maximal impulse of the heart is in normal location and there is presence of S1 and S2 with no extra heart sounds. Pt. There is no presence of pain upon assessment. Capillary refill returns immediately in 2-3 seconds. place and person.

and equality is normal. VII. Integumentary System  Mrs. it is not tender and distended with normal bowel sounds heard upon auscultation. VIII. V. VI. is pallor upon assessment. There is no bladder distention and can urinate for at least 3 – 5 times a day. There is no presence of edema or any pressure sores or ulcers. pt. Urinary System  Patient’s urinary output is normal for at least 30cc/hour. strength.IV. Bowel movement is normal for at least once a day. Musculoskeletal System  Patient’s limb movement with regard to full range of motion. Patient is on diet as tolerated. Ability to sit. turn and stand is normal but is guided and assisted with bathroom privileges. Gastrointestinal System  Patient’s abdomen is normal in size and contour. skin is warm to touch. Posture and gait is also normal. Psychosocial System . Piquero has normal skin turgor. has good appetite and no taste alterations.

 Patient has good interaction to family and also to health care providers. Patient’s Data Name: Age: Address: Birthplace: Nationality: Birthday: . COMPREHENSIVE ASSESSMENT I. Patient’s support system especially his husband and chidren is present. but sometimes she is irritable because of her illness.

Civil Status: Blood type: Diagnosis: Chief Complaint: Date & time of admission: Admitting physician: History of past illness . History of present illness .

foot strength and movement is normal. Point of maximal impulse of the heart is in normal location and there is presence of S1 and S2 with no extra heart sounds. Pt. Cardiovascular System  Patients pulse rate is normal within 88 – 96 cpm. There is no presence of pain upon assessment. II. Handgrips. can feel dizziness when standing up. place and person. rhythm and quality is also normal. REVIEW OF SYSTEMS I. murmurs or rubs heard upon .Effects of present illness to the patient/family The patient and her family expects that her illness will be cured with the help of proper therapeutic medication given by their physician and also with the help of the health care providers. Central Nervous System  Patient is conscious and coherent to time.

IV. Cough noted but there is no presence of sputum. Patient is on diet as tolerated. Bowel movement is normal for at least once a day. III. has good appetite and no taste alterations. Crackles sound heard upon auscultation. Respiratory System  Patient’s respiratory rate is normal within 22 – 26 bpm. Gastrointestinal System  Patient’s abdomen is normal in size and contour. it is not tender and distended with normal bowel sounds heard upon auscultation. Capillary refill returns immediately in 2-3 seconds. skin is warm to touch. pt.auscultation. There is no presence of edema or any pressure sores or ulcers. Musculoskeletal System . is pallor upon assessment. VI. Integumentary System  Patient has normal skin turgor. V.

Patient’s support system especially his husband and chidren is present. There is no bladder distention and can urinate for at least 3 – 5 times a day. turn and stand is normal but is guided and assisted with bathroom privileges. but sometimes she is irritable because of her illness. Ability to sit. strength. Posture and gait is also normal. and equality is normal. Psychosocial System  Patient has good interaction to family and also to health care providers. VIII. Urinary System  Patient’s urinary output is normal for at least 30cc/hour. VII. . Patient’s limb movement with regard to full range of motion.

Sign up to vote on this title
UsefulNot useful