Name of Patient: _Aladin_________________________ Age: _2 y/o_______Date of Birth: ______________

Medical Diagnosis: _Encephalitis________________________________________________________________

Nursing Diagnosis: _Ineffective tissue perfusion related to intracranial pressure________________________________________
Assessed by: ___________Date of Assessment: _October 8, 2021________Time: __10:30 AM___
Assessment
Area N AbN Description of Findings & Interpretation
General Appearance
Posture /
Hygiene/Grooming /
Nutrition/Diet /
Body Size/Habitus /
Height: ________ /
Weight: _______ /
Supply appropriate data:

 IBW: ___________ /
 BMI: ___________ / Height and weight were in the 65 percentiles

Normal Findings:
Falling between the 5th and 85th percentiles is considered normal and health
(Goldman, )2020
 IRS: ____________ /
Behavior / Increased irritability
LOC / Listless, lethargic, sleepiness
Vital Signs / Patient is febrile
Temperature: _39.8 C______
Pulse Rate: _166 bpm________ / Pulse rate above normal range
Rhythm: __________ Normal range: 70 to 120 bpm
Respiration Rate: _34 cpm_______ / Respiratory rate above normal range
Rhythm: ___________ Normal range: 20-30 cpm
Blood Pressure: __________ Not assessed
Skin /
Color
Temperature /
Turgor /
Texture /
Integrity /
Unusual Marks /
Rashes, Lesions /
Pressure sore: Yes ___ No ___ /
Site: ___________________
Edema: Yes ____ No ____ /
Site: _____________________
Type: _____________________
Size/Degree: _______________
Hair /
Texture
Thickness /
Color & Distribution /
Hygiene Status /
Nails /
Color & Shape
Hygiene Status /
Presence of Clubbing /
Head
Shape & Symmetry /
Unusual swelling / Bulging fontanelles
Cranial bruit /

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
Assessmen
Area t Description of Findings & Interpretation
N Ab
N
Eyes /
Size, placement &
alignment
Cornea /
 Pupils /
 Size (mm)
PERRLA /
Visual Acuity /
Orbital Bruit /
Other Findings: / Sunken and jaundiced
________________
Ear /
Location/Alignment
Pinna, Cannals, Drums /
Hygiene /
Discharge and Odor /
Hearing Acuity /
Tinnitus /
Vertigo/Dizziness /
Other Findings: / Erythematous, non-bulging tympanic membranes.
________________
Nose
Shape /
Symmetry /
Patency /
Mucosal Integrity /
Epistaxis /
Sinuses /
Other Findings:
________________
Lips /
Integrity
Symmetry /
Color / Pale in color
Other Findings:
________________
Mouth /
Hygiene
Number & Condition of /
Teeth
Gums / Pale oral mucosa
Mucosal Integrity /
Tongue / Pale oral mucosa
Tonsils
Palate / Pale oral mucosa
Parotid Gland /
Hoarseness /
Other Findings:
________________
Neck
Carotid Bruit /
Neck Veins /
Thyroid /
Trachea /
Rigidity/Tenderness
Mass/Bruises /
Other Findings: / Neck stiffness
________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6

Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Shape & Symmetry /
 Nipple & Areola /
 Mass/Lump /
 Others: __________
Breathing
 Spontaneity /
  With Ventilator /
 With Tracheostomy /
 Rhythm / Irregular (Tachypnoea)
 Depth / Rapid, shallow breathing
 Effort / Labored breathing or increased effort when breathing
Use of Accessory Muscles / Mild subcostal retractions.
a. Intercostals
b. Abdominal
/
c. Sternocleidomastoid
/
d. Trapezius
/
Cough /
Sputum Production: Yes __ No: __ /
 Amount: _____________ /
 Consistency: __________ /
 Color: _______________ /
 Odor: _______________ /
Chest X-ray Result /
Breath Sound (Specify) /
a. Bronchial
b. Crackles
/
c. Rhonci
/
d. Wheezes
e. Stridor /
f. Crepitus /
/
CTT /
Location: __________
Suction: ___________
/
Water Level: _______
/
Quality of Drainage: ___________
/
ABG /
Other Findings: ________________
Heart /
History
With Palpitation
/
Dyspnea
/
Rhythm / Tachycardia with a regular rhythm
Point of Maximal Impulsec(PMI)
(PMI is felt at 5th ICS at apex
of heart) Specify:
a. Heaves
b. Clicks /
c. Splitting /
d. Thrills /
e. Callops /
f. Muffles /

Presence of Heart Sounds /

a. S1
b. S2
/
c. S3
/
d. S4
/
Murmurs / 2/6 mid systolic murmur with minimal radiation
a. Systolic Audible, but faint
b. Diastolic
/

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 6
Assessment
Area N AbN Description of Findings & Interpretation
Abdomen
Diet: ____________________ /
Mode of Feeding: __________
/
Shape and Symmetry /
Umbilicus Protrusion /
Bowel Sound (Indicate Sound) / Diminished bowel sound
 LUQ: __________
 RUQ: __________
/ Diminished bowel sound
  LLQ: __________ / Diminished bowel sound
 RLQ: __________ / Diminished bowel sound
Abdominal Bruit /
Distention /
Ascites: Yes: ____ No: ____ /
Nausea /
Vomitus/Hematemesis /
Amount: _______________
Consistency: ____________
/
Color: _________________
/
Odor: _________________
Frequency: _____________ /
/
Drainage Tube /
Abdominal Mass /
Abdominal Girth: __________ /
Other Findings: ________________
Back Not assessed
 Spine
 Paralumbar
Other Findings: ________________
Genitalia Not assessed
Symmetry
Presence of Tenderness
Urethral Discharge
Bleeding
Pelvic Pain
LMP: ________________
With Dysuria
With Flank Pain
Nocturia
History of Urinary Stone
History of Impotence
With Urinary Catheter
Urinalysis Finding: _____________
Peritoneal Dialysis (PD) Not assessed
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________

Hemodialysis Not assessed

Frequency: ________________
Last HD: __________________
Amount of Fluid Removed: _____
Next HD: __________________
Place: ____________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 4 of 6

Assessment
Area N AbN Description of Findings & Interpretation
Rectal Examination Not assessed
Anal Inspection
With Hemorrhoids: Yes:__ No:__
Location: ______________
Characteristics: _________
Mass
Last Bowel Movement: _________
Characteristic of Stool: __________
Other Findings: ________________
Nodes
Lymphadenopathy / No lymphadenopathy
 Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________
Extremity
Texture /
Capillary Refill / Within 2 seconds
Peripheral Pulse (both sides)

 Carotid /
 Radial / Bounding pulses
 Ulna /
 Brachial /
 Femoral / Bounding pulses
 Posterior Tibial /
 Dorsalis Pedis / Bounding pulses
 Popliteal /
Clubbing of Fingers /
Varicosities /
Thrombophlebitis /
Cyanosis /
Joints
 Erythema /
 Tenderness
 Deformity /
 Swelling /
/
Muscles
 Bulk /
 Tone
 Tenderness /
/
Ulcerations /
Edema /
Other Findings: ________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 5 of 6

Assessment
Area N AbN Description of Findings & Interpretation
Hematopoietic Not assessed
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings: ________________
Neurology

Assessment of Cranial Nerves

 CN I (Olfactory) /
 CN II (Optic) / Sensitivity to light
  CN III (Oculomotor) /
 CN IV (Trochlear) /
 CN V (Trigeminal) /
 CN VI (Abducens) /
 CN VII (Facial) /
 CN VIII (Vestibulocochlear) /
 CN IX (Glossopharyngeal) /
 CN X (Vagus) /
 CN XI (Spinal Accessory) /
 CN XII (Hypoglossal)
Motor and Posture / Patient is listless though attempts to follow commands

Sensory Perception / Not resisting or crying in response to aggravating stimuli

Reflexes /
a. Indicate Type of Reflex______
________________________
b. Pathologic Reflex: Yes__ No__
/
Other Findings: _________________
Patient’s ADL

a. Bathing /
b. Dressing /
c. Elimination /
d. Mobility and Movement / Lethargic
e. Nutrition and Feeding / Decreased oral intake

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6