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MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City I. ASSESSMENT A. General Data Patient’s Initials: Address: Informant: Age: Date of Admission: Sex: Order of Admission: Date of Birth: No. of Days in the Hospital: Occupation: B. Chief Complaints C. History of present illness D. Past History: 1. Childhood Illness: 2. Adult Illness: 3. Immunization (date) 4. Previous Immunization (date) 5. Operations (include year) 6. Injury (include year) 7. Medications taken prior to confinement (6 months) 8. Allergies E. System Reviews: Gordon’s Eleven Functional Areas (Narrative form 1st Paragraph- previous health 2nd paragraph- present) F. Family Assessment (tabulated) PATIENT NOT INCLUDED.
Name Relation Age Sex Occupation Educational Attainment
G. Heredo-Familial Illness Maternal: H. Developmental History
Age Task Patient description
I. Physical Examination Date & Time: Height Actual Height: Anthropometric Measurements: (for pedia 0-3 years old) Head Circumference: Chest Circumference: Abdominal Circumference: Temperature: PR: RR: BP: Regional Examination A. Skin Inspection: Palpation: B. Nails Inspection: Palpation: C. Head and Face Inspection: - A symmetrical, lesion-free skull - Symmetrical facial structures with normal variations in skin texture and pigmentation Palpation: - Ability to shrug the shoulders - No lumps or tenderness - Symmetrical strength in the facial muscles - Symmetrical sensation when you strike a wisp of cotton on each cheek D. Eyes Inspection: - No edema, scaling, or lesions on eyelids - Eyelids completely covering corneal when closed - Eyelid color the same as surrounding skin color - Palpebral fissures of equal height - Symmetrical, lesion-free upper eyelids that don’t sag or droop when the patient opens his eyes - Evenly distributed eyelashes that curve outward - Globe of the eye neither protruding from nor sunken into the orbit Actual Weight: Ideal Body Weight:
Lesion-free tonsils Palpation: .Symmetrical to facial structures .A patent external meatus . or lesions in the cervical spine I. ulcers r lesions .2 .No eyelid swelling or tenderness E.No tenderness or nodules on the floor of the mouth H. bony edges on the mastoid process with no signs of tenderness F. lesion-free nose with no deviation of the septum or discharge .Unrestricted range of motion in the neck .No redness or swelling Palpation: .No bulging of the thyroid .No tenderness on the posterior and lateral surfaces of the tongue . with no deformities .Indentified familiar odors .Eyebrows are equal size.No edema on the frontal and maxillary sinuses . equal size that react to light and accommodation . Neck Inspection: . coating. color.Long axis of the ear perpendicular to the eye-occiput line .Symmetrical pulses in the carotid arteries . Ears Inspection: .Visible salivary ducts with no inflammation .Clear conjunctiva with visible small blood vessels and no signs of drainage . lesions.Non-visible jugular veins Palpation: .No evidence of foreign bodies or dried blood nose Palpation: . and distribution .No cracking.Normal chest shape.No intercostals.Tip of ear crossing eye-occiput line .No signs of inflammation.Mobile.Constriction of both pupils when you shine a light on one .Parallel eye movement in each of the six cardinal fields of gaze Palpation: . Mouth and Pharynx Inspection: .No tenderness or edema on the frontal and maxillary sinuses G. nonpalpable lymph nodes on the auricle or discrete.Either small. substernal.No structural deviation. symmetrical.Pink color of lips .No tenderness on the auricle or tragus during manipulation . Spine Inspection: Palpation: J.No visible discharge from the auditory canal . or swelling on the external nose .Lips free from pain .No lesions and inflammation on the posterior pharynx . proportionately sized auricles .Pink-red nasal mucosa with no visible lesions and no purulent drainage . or modules . tenderness. mobile lymph nodes with no signs of tenderness . lesions or cyanosis . tenderness. hard palate .Symmetrical lymph nodes with no swelling .Absence of nystagmus .All teeth are intact . soft lymph nodes with no tenderness .Little or no nasal flaring .Skin color on the mastoid process that matches the skin color of the surrounding area .White.Well-defined.Pink soft palate .Proper eye alignment . lesion-free thyroid with no tenderness . Thorax/Lungs Inspection: .A palpable. Nose Inspection: .Color match between the ears and facial skin .Midline location of the trachea and absence of tracheal tenderness .Round.Ability to open mouth and close mouth easily . or abdominal muscles .White sclera visible through the conjunctiva .Quiet respirations with no use of accessory neck.Pink gums with tartar .Symmetrical.Pink tongue that protrudes symmetrically and has no swelling.No masses or tenderness on the auricle . shoulder.Bilaterally symmetrical. or supraclavicular retractions biancapaigecastrencegonzales maniladoctorscollege .No crepitus.Symmetrical side-to-side configuration of the chest .
Normal adult respiratory rate .Flat. fremitus.Abdominal musculature free from tenderness and rigidity .3 .*mitral area (It sounds longer than s1 sounds) .No tenderness or masses .No apparent bulges .No pulsations except at the PMI and epigastric area Auscultation: . friction rubs. with a flat or concave hemisphere .*aortic area (It sounds shorter.Skin color matches the body’s complexion Palpation: . Extremities Inspection: .Equal bilateral limb length and symmetrical muscle mass Palpation: .2nd heart sound (dub). abdominal aorta. bladder.No visible pulsations. higher. heard every in all four quadrants of the abdomen .Symmetrical strength in the facial muscle (CN V and VII) .Umbilicus positioned midway between the xiphoid process and the symphysis pubis.No visible swelling or inflammation of joints or muscles . tenderness. distension.Ability to shrug the shoulders (CN XI) . including the stomach.Vascular sounds heard through the bell of the stethoscope .Loud.Symmetrical body parts . texture. surgical scars.Abdominal movement apparent with respirations Auscultation: .Equally strong bilateral pulses O.No gross deformities . liver.Normal shape with no swelling or tenderness . or subcutaneous crepitation Percussion: .Skin free from vascular lesions.No involuntary contractions or twitching .Warm dry skin .No detectable vibrations or thrills .Symmetrically expanding chest wall during respirations .No variations in skin color .Equal bilateral muscle tone. pancreas Palpation: .No assymetrical expansion. and below the clavicles .Symmetrical abdomen .No involuntary movements . except at PMI .Regular respiratory rhythm.Intense.Soft.No lifts or retractions in the four valve area of the chest wall Palpation: . Abdomen Inspection: .Dullness over solid masses including kidneys. Rectum and Anus Inspection: Q. Cardiovascular/Heart Inspection: . breezy.Full range of motion in all muscles and joints .Smooth gait . low-pitched vesicular breath sounds over the most of the peripheral lung fields K.Good body alignment . with expiration taking twice as long as respiration . or ascites N.Tympany predominantly over hollow organs. Genitals Inspection: P. intestines. and louder than S2 sounds) .No bruits. and strength . sharper. Neurologic Exam .Resonant sound over the lungs Auscultation: . or other venous hums Percussion: .High-pitched bowel gurgling sounds.No guarding. high-pitched bronchial breath sounds over trachea . and gallbladder . round abdominal contour .No pain in full ROM .1st heart sound (lub). jaundice. Breast Inspection: Palpation: M.Lub (s1)-Dub (s2) sound .No murmur L. and rashes . spleen.Closing of both lids when you stroke each cornea with a wisp of cotton (CN V) biancapaigecastrencegonzales maniladoctorscollege . medium-pitch bronchovesicular sound breath sounds over the mainstem bronchi.No tender spots or bulges in the chest . murmur. between the scapulae.
PERSONAL/SOCIAL HISTORY Habits: Rank in the family: Vices: Travel: Lifestyle: Educational Attainment: Social affiliation: Client’s usual day like: K.Treatment H.Exercise T. DISCHARGE PLAN M.Neonatal History: .Complications after delivery: .Uvula moves upward when the patient says “ah” and a gag reflex that occurs when a tongue blade touches the posterior pharynx (CN IX and X) J.Health Education O.Ability to move tongue easily and without tremor (CN XII) . PATHOPHYSIOLOGY A. Client Based O. NURSING CARE PLAN Cues/Needs Subjective Data: Objective Data: Nursing Diagnosis Rationale Goals and Objectives Interventions Rationale Evaluation S.Exposure to Teratogenic Agents during Pregnancy: Neonates ONLY: .) T. OB/GYNE HISTORY (FOR FEMALES ONLY) Menarche (age): When: Amount and Characteristics: Duration: Associated Symptoms: Deliveries: G __P__ Operations: OB Score: T __P__A__L__ M. LABORATORY RESULT OR FINDINGS (date and time) Laboratory (date) Normal Value Result Interpretations/Significance P. ENVIRONMENTAL HISTORY (Living/Neighborhood circumstances) L.Feeding History: . ONGOING APPRAISAL (A comprehensive summary of patient’s daily health status to include medications.OPD follow-up D.Ability to purse lips and puff out cheeks (CN VIII) . PEDIATRIC HISTORY MATERNAL AND BIRTH HISTORY Birth Date: Hospital: Birth Weight: Type of Delivery: Condition after birth: Mother: .Type of Feeding: N.Anesthesia drug during labor: . DRUG STUDY (client based) Drugs Date Ordered: Generic Name: Classification: Dosage: Indications Contraindications Actions Drug Interactions Side Effects/Adverse Reaction (per system) Nursing Consideration Assessment: Implementation: Patient/Family Teaching: Q. Theoretical Based B. LIST OF PRIORITY PROBLEM R.Signs and Symptoms biancapaigecastrencegonzales maniladoctorscollege .Diet S. procedures.Medication E.4 . Laboratory done in collaboration with other members in Healthcare team.
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