y UNIVERSITY OF CEBU BANILAD COLLEGE OF NURSING CEBU CITY PHYSICAL ASSESSMENT FINDINGS Date of interviews, PATIENT'S PROFILE Patient's Name <—— Nationality Religion Occupation. _ Date of Birth Hospital Date of Admission Physician, Medical/Surgical Diagnosis, —_ ‘Temperature Sf Porat 1 [axtila 1 [rectal Pulse =— 7 fregular —/ fieregutar Blocd Pressure f Tiyiog / Jsitting 7 {standing Respiration 7 [regular / irregular Height ‘i cm, BML Weight eg. Waist tohip ratio IV, CHIEF COMPLAINTS / REASON FOR HOSPITALIZATION V. ‘HISTORY OF PRESENT ILLNESS (Focus Assessment) Character : Onset Location Description: Severity Pattern Aggravating. Alleviating aout rinseauaserssur pons 1/6PAST HEALTH HsTORY A. MEDICAL / SURGICAL HISTORY Unremarkable :. Mrémarkable : Remarkable B. PAST & CURRENT MEDICATION Drug & Dose , Frequency C CIILDHOOD.ALLNESSES Date E, IMMUNIZATION ce MMR ory per HEP.A HEP. B MENINGO. Hib Vil, FAMILY HEALTH HISTORY : 1vEs No wio Heart Discase Hypertension stroke Tubcreulosis Diabetes Mellitus Cancer + Kidney Disease Blood Disorder Astiuna, ADULT PHISKEAL assessMrEN Finoins 2/6VII SOCIAL HISTORY Alcohol Use (Type____ amt. / Day__) Druguise (type. ‘Amt-] Day.) Tobacco Use (No. OF Packs/Day. ) Sexual Practice Work Envitonment Travel History Home Environment Domestic Violence Hobbies & Leisure Acti Economicstatus Education ADL 1X HEALTH MAINTENANCE ACTIVITIES Sleep Examination Pattern, Dict Exercise Rest Stress Management Health Check-ups Use of Safety Measures X. REVIEW OF SysTEMS Ears Nose & Sinuses Mouth ‘Throat &Neck Breast & Axilla Respiratory Cardiovascular / Peripheral Vasculature Gastrointestinal Urinary Musculoskeletal Neurologicat Psychological Female Reproductive Male Reproductive Nutrition Endocrine Lymph Nodes Hematological ADDITIONAL INFORMATION : roxnr onrseacassssutar nos 3/6University of Cebu Bantlad College OF Nursing” Cebu City ADULT PHYSICAL ASSESSMENT FIDINGS * Patient's Name: Age: Sox, Civil Status: Date of Birth: Place of Hirth: = 1._ Odor __2._Color. — ~ 73. Lesions — 4, Texture — — 6 - =. 7. 8: = - Z - 9. SSS SE ESWEAD AWD FACE i. Inspect and palpate the head for size, shape, _and configuration" Note consistency, distribution, and color of hair 3. Observe face of symmetry, facial features, expressions, and skin condition. a 4 Check function of CN Vit: Have the elient ° smile, frown, show teeth, blow out cheeks, raise eyebrows, and tightly close eyes. : . 5. Evaluate function CN V: Using the sharpand dull sides ofa paper clip, rest sensation of forehead, cheeks, and chin. 6. Palpate the temporal arteries for elasticity and tenderness. _ 7. As the client opens and close her mouth, palpate the temporomandibular Joint for tenderness, swelling, and crepitation. Determine function Perform cover Viests 2. Inspection external Eye: Fosition and alignment of the eyeball Inthe |__. ket ie —~—Bulbar conjunctiva Lacrimal apparatus etiy und for colour and lesion ~~ Fovea centralis (sharpest area of vision) and macula Anterior chamber for el: ity Inspect the auricle, tragus, and lobule for shape, position, lesions discolorations, and . ___ discharg. 2. Palpate the auricle and mastoid process for tenderness. sour movscacassessiear vos 4/6Use the otoscopeto inspects ie) External auditory canal for colourand ... ' cerumen (ear wax). ‘Tympanic membrane for colour, shape, consistency, and landmarks, * . . ‘Test hearing: : Te : NORE AND SINUSES = 1. Inspect the external nose for colour, shape and consistency. Palpate the external nose of |, tenderness. 2 2. Check patency of airflow through nostrils {occlude one nostril at a time and ask client to . . snif). _ 3. Test CNT: Ask the client to close his eyes and smell for soap, coffee, of vanilla. (Occlude' each : nostril). 4. Use an oloscope with a short wide tipto ° inspect internal nose for colour and integrity of nasal mucosa, nasal septum, and inferior and _middle turbinates. “5, Transilluminate maxillary sinuses witha _penlight to check for fluid or pus = <2 S MOUTHAND THROAT 1._Inspect lips for consistency, colour lestons. 2. Inspect the teeth for number and condition. 3. Check the gumsand buceal mucosa for colour, consistency, lesions. 4. Inspect the hard (a and soft (posterior) palates for colour and integrity. 5. Ask the client to say “aah” and observe the : _fise of the uvula. : “ : 6. Test CN X: Touch the soft palateto assessfor | gag reflex. : 7. Inspect the tonsils for colour, size, lesions, and exudates.” @. Inspect the tongue for colour, moisture, size and texture. 9.” Inspect the ventral surface of tongue for frenulum, colour, lesions and Wharton's ongue strength | byasking client to press tongue against : | tongue blade. . | 12. Assess CN VII and CN Ix; Have the patient j close her eyes, Cheek taste by placing salt, ‘ | sugar, and lemon on tongue. 1. Inspect neck for appearance of lesions, masses, swelling and symmetry. ._Test range of motion (RO ‘3. Palpate the pre-auricular, occipital, tosillar, submandibular, and submental nodes. Palpate the thyrold gland for siz irregularity or masses. "7. Palpate carotid arteries and L__bruits. buat evrsiens assessment rnveincs 5/6STG ARMS HANDSAND FINGERS (SE “[nspect the upper extremities for overall skiti coloration, texture, moisture, masses and lesions. ‘Test function of GN X1- Spinal by shoulder shrugand turning head against resistance. Palpate shoulders and arm for tenderness, swelling and tempe 4. Assess epitochlear lymph G.Palpate the brachial pul 7. Palpate ulnar and radi 8. Test 9. Inspect palms of hands and palpate the temperature. 10. Test ROM of the wrist. 14, Usea reflex hammer to tes biceps, wiceps, and brachioradialis reflexes. 13. Ask the patient to,close her eyes; test sensation. Remarks: ‘Student's Signature over Printed Name Clinical Instructor CRITERIA : © Accuracy (50): ‘© Comprehensiveness (5): + Completeness (20): + Neatness (ee Total (100) : Year & Section Date ous rien assssnens nes 6/6: UNIVERSITY OF CEBU : College of Nursing untversity oF cebu Cebu City PERFORMANCE EVALUATION CHECKLIST. . : AREA: Medical = Surateal Unit ‘Name of Student: = | Year Level: ~ | School Year _ ‘ Semester: | Inclusive Dates of Clinical Rotation: -} 7 z 7 To | Competencies : Above etow | Remarks’: excatgs| A008, | averaae| Sat, 1, Sato and Quality Nursing Gare = I 1._Assesses tha healt needs ofthe cleat [ee Te | Performs appropriate assessment techriques. I : _ Identifies client's wellness, actual or potentiat health problem. ‘ | “._ Determines appropriate nursing care toaddresspriorlyneeds! | problems. | 3. Performs comprehensive Gist ars plan or prevention of problems or enhancing wellness response. : we | ©. Performa soe opeciic safety and comfort measures inal i tepects of chentcar. 7. Referred idenfed problem tomemberls ef heatthieam, | am 8. Conforms tothe ten (10) rights nmadicaton administralen. | | 9. Explons interventions to client andfamiy before performing | procedure ae | 70, Pertormsncrang actvies eteclvaly Tob i 11, Evaluates effectiveness of nursing intervention . | TL Management of Resources and Environment : zl 71. Orgunizes wartoad to facilitate client care. 2. Identifies tarks oractiviies thatneed tobe accomplished | 7 | 3.” Performs nursing care based on the sel standards or regulations. “4, Ghecks proper functioning of equipment io be used In| pertormingnursing procedures. 5 Adherestops les. procedures, and protocolon maintaining tafe environment. 1 I 6. Finishes work assignment on time. | Teal Eavealon 7 : 7 { 1._Formulales a comprehensive health education plan. I 2, Involves the ellen, family andS.0 In conducting heath | education, 3, Utilizes information education materials apprepriaio to ths fove of theelient. . “4.__ Provides a conducive pallent learring situation. “G.__ Responds to question of the cient or relatives, IV. Legal Resporsiotities _ 4.__ Documents all pertinent data correctly and complet 2, Checks the completeness of informed consent and ether legal forms. ‘Observes confidentially or the Privacy Act policy when dealing with hospital and patlents' records. “@.. Acts in accordance with the rules and regulations of the Institution, ‘Moral Responsibii Respects the religious, cultural, and ethnie practices of tho | client, l 2, Randers nursing care consistent with elient's bil ef rights. | 3._ Maintains privacy and confidentiaity of patient dala ar Aatoresto Uw potelea cl tho natillons, L I4 Below | Remarks Competencies i Excotont ele |; Personal and Professicnal Daveloprient 7, Demonstrates godmenners and right conduct at ell times. "2. Wears the prescribed uniform. 7 3. Demonstrates congruence of words and ection, ‘Behaves appropriately at all mes. T 3. Sets atsinable objectives to enhance nursing knowledge and lls Vil Quality lnprovement 7._Identifies significant changes In clent’s condition. 2. Shares withthe team the relavantinformetion regarding client's gonaition. " 3. Performs dally cheek of client's record? condlion.. : <2 pecans sd cera uring care rdctons 4 eae i Wi Researeh 71._ldentfios researchable problems regarding eliont care. 2, Uiizes findings In researchin the provision af nursing care to: ied [Be Records Managernent c | | 7L_Documerts accurately the relevant data ofthe patent | 2. Wantaina an ergunized eystom offing and recordkeeping { Z._ Obeerves confkdentiaty and privacy of ellente records. 1 2 Fallows protocol releasing formation abovt We cle | X Communication t 4. Utlizes appropriately allforms of communication. 2_Waintains an open ine of communication with clent andS.O. 3. Lstens actively 6 cients concems, SO.and members of the heatthteam. [A Collaboration ond Tearmwork 1 1. Participates actively ia client care and communicates findings of assessment to all concern. st . 2. Maintained good interpersonal relationship with clients and { ‘ether members of the health team. [2 Respects tne role of other members of the health team. | Evaluation: - Student's Comments: ‘Student's Signature E.'s Signature Date2. Fornintion if Nursing [2a Stated clearly: 2 Priontizes nisin ce Bn 3 Utilized specified parts af T 1 eongraent a i 3.2 sound, 2 3.1 scistiie, {F--4. Goat sétning/Onteome Gritsrin : t 4.1 Spetifie —. 4.2 micasmable 4.danoinable, { 4.4 renlistic : (= 4 Sume-bounded- AG relevance intervention/Nursing Avtin ‘S.S-appopriats, 52 prioritized z $.3 comprehensive in termaof $.4 promotions 5 5.5 prevention ~ 5.6 curalive 5.7 tehabilitation 2 6, Evaluation 6.1 based of gon E 6.3 “revised cars tecarding te Gvahinie 264 minde neccksiry referrals i z 7 Documentition: = 7.1 scionlifie funtnoung, 7.2_bibliogfaphy ‘doa Discharge Plan 8.1 ullized the nufsing process appr 2 rineneparated focus or health teaching (Ml 8.3, completeness, £ R.4_ correctness ss beat 9... Prompting WOaNeainess