St.

Anthony’s College
San Jose, Antique
Nursing Department

I. VITAL INFORMATION
Name:
Age:
Address:
Civil Status:
Sex:
Religious Affiliation:
Date and Time Admitted:
Chief Complaint:
Date of Interview:

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. History of present illness

Prior to
2. Past Health Problems/ Status
a. Childhood Illness:
b. Childhood immunizations:
c. Allergies:

3. Family history illness

4. Patient’s expectations

5. Patterns of Functioning
a. Breathing Patterns
b. Circulation

c. Sleeping Patterns
Usual bedtime:
Number of pillows:
Bedtime rituals:
Problems regarding sleeping:
 d. Drinking patterns
Kinds of fluid intake in 24 hours

Morning Evening Weekends

e. Eating Patterns

Usual Food Taken Time

Breakfast
Lunch
Dinner
Snacks

Food Likes:
Food Dislikes:

f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems or difficulty:
Usual Remedy:
2. Urination
Frequency:
Problems or difficulties:
Usual Remedy:

g. Exercise

h. Personal hygiene
1. Bath
Type:
Frequency:
Time
2. Oral Care
Frequency:
Care of dentures:
 i. Recreation

B. PSYCHOSOCIAL ASSESSMENT
1. Psychosocial Nursing Assessment
Lifestyle information:
Normal Coping Patterns:
Personality Style:
Recent Life Changes or Stressor:
Major issues raised by current illness:

2. Mental status Examination

Appearance:

Behavior:

Speech:

Mood/Affect

Thoughts:

Memory:
Impaired recent memory:
Impaired remote memory:

Concentration:
 General appearance:
 The patient has no Physical deformities or abnormalities.
 The patient showed no sign or potential sign of distress.
 Patient’s nutritional status and body built is appropriate to her age.
 The patient is relaxed, no involuntary movements.
 Patient’s mood is appropriate to the situation, comfortable and calm
 Patient is physically looks clean and neat.
 Patient is asleep most of the time

CEPHALOCAUDAL PHYSICAL ASSESSMENT

INTEGUMENT
Skin
-
-
-

Scalp
-
-
-

HEAD
Hair
-
-
-
Skull
-
-
-
Face
-
-
-
Eyebrows
-
-
-
Neck
-
-
-
EYES and VISION
Eyes
-
-
-
Eyelashes
-
-
-
Eyelids
-
-
-
Sclera
-
-
-
Cornea
-
-
-
Pupil
-
-
-
EARS and HEARING
Ears
-
-
-
Nose and Sinuses
-
-
-
Mouth and oropharynx lips
-
-
-
Gums
-
-
-
Teeth
-
-
-

Tongue

-
-
-
Uvula
-
-
-
Thorax and Lungs
-
-
Abdomen
-
-
-

Musculoskeletal system
-
-
-
Mental status