You are on page 1of 4
Comprehensive Nursing Assessment and Care Plan GUIDE Comprehensive Adult History and Physical* Dato of Vet Madical Racor # sacks —___ Telephone: (bors) (business) IniemanRetatnshi Dato of ir ‘Age: Gender: Male. Fomale Language Iniprotrprosont. C1¥e= CONo Prosar etabti: C1 Adequate C1 inadequate a COC Sn See eee’ Ses. COCA CDais tc Ossie C9 Cridhoed (Othe of Above Nnssos Oak hardens: 1 popenscony Dowkejteony 1a ea Medication itera Cor D taper OViamins Tl ossin cn Csipromentstatas Dopey: Sone ‘Boge De nironment ‘Doss ex veentast PEE Menta Ages! menace we contacts: Inert Duratan ow ‘Sunual Actvi Avg inoy Cccansing Cimrnnstoa Bonsty OPUS Fy sneer Ceppostssec dst Obsotiest GTP DBsingopatrer — CO mutes O>stteume pats campleator: ST hx: Meropaese: 98 Atl lesng ——— concer: Symptons Hoon VERT CORT Doc “Fram Lon L205), Princ toe or cinta S. Lows Bs Comprehensive Nursing Assessment and Care Plan GUIDE Comprehensive Adult History and Physical - 2* Patent ha: Dato Bi ate of Ea Mortal tau: OVS CMarisi —DomesiParver CI Fal History Uninown dheess hWaoved Fata Cohaionts: Mater: aie Siig: Etoestion Se Occrpaion _________ mor Ietrst citi: am: xarege: C101 Chwwigs or. Diet Ci ealaoe6 Cals Pom Soap Rest Cate: To Ces copay ter Tobacco: No) Yes PPD___#Yours_ out Yar Smeg inhae: Ces Wo ETOH: CVYes Chno Choaly Cary Fon # ins utara nonce: Recreational Drage Suppor SstemsCoping Skis: VAdewaie Chinas ‘Eon [LastDate| Results [NA] Rehsed Past uso io SBETSE en Sto gue pid roe exiles] BS. ox PSA £08) PPD vans ae we i aS pote | semis [Pina wnt [Tsuneo [CF Occuaod ‘area wedrleoensce emo (snc Deaors [PYHcuuno [Pon Vownce [Charms Cermak cine levis Cnbtsiats Sisto Clumehimivesties vet ann Cannes: ave Cipurts One Chris Clunionerson Clngrenctme noes Cvnting Clays Cimekoe igi Cite Clic Clonee Ctexnglss Climbs Clvseneige Cleanse Cleassictang Ceisistunctise Clq Cries Custeopatin Cpatast ap lsh in Closet Chyteer Claret naa Crome Cate Cusanggine Cause awed: Cah Champs Cdchage Cebit dns Cin Drm: eu Ossa Crem soe Ceanm sre Cares Cope Dor Casta Cmpeans Soe Comes OP Cepmese Cgnen Cnatmumur Copesme Dem Coawsecon chatsmewns Combate Code eames koe Fa Cows CmDon Congo nent: Crooks Crim Coemieg Citrine Cistantal ah Cloeire estar Cen Cloxsipaon Coaven Cube Ciaexuiy CIBAPR CleameingN Cremaroe: Cvana Dar Ogee Cun Creueey Crm Creare Cpaure Csipante pan Ciunkpin Creme Coe eng Clocte weesram Cisteurpan Cece mavsraing Ci axe Ceeateasuncim lvgtalaeaye Cains ChaspuentaCJsoua stinging Cleoehes Ceyptan Chew Sooner Cunpintet amps cbame Crarstage syhusre Cocengans Cutrgoisimmuoxenertns Clneinnens Takes Cees aro Biase paoan etn Clea: Cnsivetononeten Covsng Carmen vryochmty cimgioa Clmumibcanoe —Clwatnes Clapeoat ctaean ase: loads Cipsrns Cronies Come Clave Cispeoe Costas Coneney iee Cotase Beer: Csmay Covtesteas Clagresion Creataanss Cimanty Crees Camas “From Lore. (2005, Payee tal orcas. Leis sever hs Ca PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Svat Eo, {abnor Mana Copyright© 2016, 201, 205, 205,20, 198 by Sunde an iment of Hae ne Alright er Comprehensive Nursing Assessment and Care Plan GUIDE Comprehensive Adult History and Physical - 3* Patios Nome: at of Br Dat of Ea: Physical Exam AzAbnormal___(Grackagpropiatebog| | 8 1. Genera faperane: aye LOC = tion +deeopment+ metals = hee 2 Suis yiaton le ee «ara = ios 3. Haade saga soa syntty+ sep loses 4 Frs| is sunt sa tec Muss ova Pais: su, econo gh and acormadacn Fun Fas: sm cna Ts aang Mase: pte vas esses mal mucosa sect turbiats 7. Mouth: ips guns = ah mucosa pale orgie 2 That payne ows wl Neck: ROM esjnnoty «papaya Wathen artis jugular ves mph nodes 7, Beasts: rma «hn «ips = paaon + nos 1, resungs: exci epakaton «pression asc 12 Carat: Ue papain eral we» 2 rus alos «rts rt suns 7, Abdomea: agpearance bowl sounds Bs» prssin| aban thet apes fink surat hes 14, Arora | ian digi a sol gua rest er paar Wir ma aOR Ira vaginal uct cave Bran agin centers ad 16 Male Genitalia: pos serctum tees ern 17 Lymph Nodes: va stclvin alana oe 18 Masculsolta|Sc¥ Su RON plan gr ey ROU sen pan Lore xen ROM srrat= rap 18 Pahoa | Uns ete. uses apps er Nascla_|Lowu ery sls apearaeo «up "Oi Mesrlogie canal neues +more sensory cabal aloes gt onal ius 16 Female ental: om La L208). Primary reals cine. Lave: Beever vate Ht___ wt_Terp_Posp_ lt 8 upright (sine). Set Ines Visca Acuity Rigt let Coneewelnees vee 1 wo Document Abnormals (by number)/Comments EDS vs Cai PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Sth Eo, Aabotory Mana Copyright© 20162012, 205, 205, 20, 18 by Sunde an iri of Eevee Alright ered Comprehensive Nursing Assessment and Care Plan GUIDE Comprehensive Adult History and Physical - 4* Pato ane Duteof Bi: xeon, PSS Periodic Health Screening Plan ban Palored| Scheduied [WA] Roles | | knnunzatons urea 16s COND paaran Voccne | Gon | Plated | Reneé Manoa 7a Pape ropa Poste Bam inten —| Testo Preumonia | geal ech cope Bi Fle grcosopyCeonoopy Bove Desy ry Ta Pro Jom Tupi CO onaveun Cn ees Goacwr Cue OSH Pee En Ceecioites Cres CluMuc smoking exssatin Fone Baeobotug Use overt, ‘vtaminscaeum Parade Dentasion care melon Dsinewosue Csannaraiines sues sus, ‘Dssey: Weapons Domest Vleme Oserse _ Osea! esa Deortacspion Frowder® Sanaire Tae ‘king wivrorer otatyONR, ‘Nae setter “Fram Lantz. (208), Pray ea to forint. 8. Lous: see Ica ACSICAL AMINATION AND HEATH SESSMENT Sth ith {abnor Mana Copyright© 2016, 201, 205, 205,20, 198 by Sunde an iment of Hae ne Alright er

You might also like