Cebu Institute of Technology –University College of Nursing Nursing History And Physical Assessment I.

PATIENTS’S PROFILE
Name of the Patient:___________________________ Name of the Hospital: ____________Ward no:___ Bed no:___ Age: _____ Sex:_______ Weight:________ Height:______ Civil Status: __________ Religion: ______________________ Address: ___________________________________________ Date of Admission: _____________ Attending Physician:

PATIENT’S MEDICAL HISTORY
1. Immunization received:___________________________ 2. Allergies: Food:_____________ Drugs:______________ 3. Heredo- Familial Disease:_________________________

Others:__________________________________ 4. Previous Surgery: _______________________________ 5. Past Medical History: ____________________________ 6. Recent Exposure to Communicable Disease: __________

Current Medication List:
Name of Drug Dose Route of Administration Frequency

II. ADMISSION DATA’S: Date Admitted: _________________________ Time: _________________________________ Mode of Admission: _____________________ Source of Information: Patient: _______________ Parents:_______________ Family Members: _______________ Relatives: _________________ Problems/ Urgent Need on Arrived: _________________________ Action Taken: __________________________________________ Admitting Diagnosis: ____________________________________ VITAL SIGNS ON ADMISSION: Temperature Pulse Rate Respiratory Rate Blood Pressure Remarks VITAL SIGNS ON ASSESSMENT: Temperature Pulse Rate Respiratory Rate Blood Pressure Remarks .

PHYSICAL ASSESSMENT ASSESSMENT FINDINGS REVIEW OF SYSTEMS BODY PART SKIN HAIR NAILS HEAD FACE EARS EYES NOSE SINUSES MOUTH .III.

BODY PART ASSESSMENT FINDINGS REVIEW OF SYSTEMS THROAT NECK BREAST AND AXILLAE HEART AND PERIPHERAL VESSELS UPPER EXTREMITIES ABDOMEN ANUS AND RECTUM GENITALS LOWER EXTREMITIES .

TRIGEMINAL SENSORY SENSATION OF FACIAL SKIN & ANTERIOR CAVITY VI. CRANIAL NERVE ASSESSMENT CRANIAL NERVE TYPE FUNCTION ASSESSMENT RESULT I. OLFACTORY SENSORY SMELL II. TROCHLEAR MOTOR SPECIFICALLY MOVES EYEBALL DOWNWARD AND LATERALLY V. OCULOMOTOR MOTOR EXTRA OCULAR EYE MOVEMENTS IV.IV. OPTIC SENSORY VISION & VISUAL FIELDS III.ABDUCENS MOTOR MOVES EYE LATERALLY .

VAGUS MOTOR & SENSOR SENSATION OF PHARYNX & LARYNX.CRANIAL NERVE TYPE FUNCTION ASSESSMENT RESULT VII. HYPOGLOSSAL MOTOR PROTRUSION OF TONGUE: MOVES UP & DOWN AND SIDE TO SIDE V. ACCESSORY MOTOR HEAD MOVEMENT SHRUGGING OF SHOULDERS XII. AUDITORY VESTIBULAR BRANCH SENSORY EQUILIBRIUM IX. GORDON’S HEALTH PATTERN . FACIAL MOTOR & SENSORY FACIAL EXPRESSION VIII. SWALLOWING VOCAL CORD MOVEMENT XI. GLOSSOPHARYNGEAL MOTOR & SENSORY SWALLOWING ABILITY. TONGUE MOVEMENT AND TASTE X.

METABOLIC PATTERN ELIMINATION PATTERN ACTIVITY EXERCISE PATTERN SLEEP-REST PATTERN COGNITIVE-PERCEPTUAL PATTERN SELF PERCEPTION.HEALTH MANAGEMENT PATTERN NUTRITIONAL.SELF CONEPT PATTERN ROLE-RELATIONSHIP PATTERN SEXUALLY-REPRODUCTIVE PATTERN COPING-STRESS MANANGEMENT PATTERN VALUE-BELIEF PATTERN .HEALTH PERCEPTION.

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