MINDANAO INSTITUTE OF HEALTHCARE PROFESSIONALS, INC.

Marawi City

PHYSICAL ASSESSMENT

NAME OF STUDENT: _____ SCORE: ________________

AREA OF ASSIGNMENT: ___ CLINICAL INSTRUCTOR:
DATE OF SUBMISSION: _______________________

PATIENT’S PROFILE

Name: Age: Sex: Status:

Address: Religion:

HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco
2. Alcohol
3. OTC drugs/non-prescription drugs

A. Chief Complaints:

B. History of Present Illness: (location, onset, intensity, duration, aggravation and alleviation, associates symptoms, previous treatment and result, social and
vocation, responsibilities and diagnosis.)

C. History of Past Illness: (previous hospitalization, injuries, procedures, infectious diseases, immunization/health maintenance, major illness, allergies,
medications, habits, birth and developmental history, pattern of sleep, exercise and nutrition.)
 D. Family History with Genogram

Legend:

Male

Female

Patient

Acquired diseases: Heredo – familial Diseases:

Hypercholesterolemia Diabetes
Kidney Disease Heart Disease
Tuberculosis Hypertension
Alcoholism Stroke
Drug Addiction Cancer
Hepatitis A Arthritis
B Rheumatism
C Allergies
Others (Pls. Specify) Asthma
Epilepsy
Mental Illness
Others (Pls. Specify)
E. Patient Perception of

Present Illness:

Hospital Environment

F. Summary of Interaction
 REVIEW OF SYSTEM

Name of Patient: Date:

Vital Signs:
Temperature: Height:
Pulse: Weight:
Respiration: Blood Pressure:
Observation:

1. GENERAL

2. HEENT H-

E-

E-

N-

T-

3. Integumentary
4. Respiratory

5. Cardiovascular

6. Digestive

7. Excretory

8. Musculoskeletal

9. Nervous

10. Endocrine
 NURSING ASSESSMENT II

Name of Patient: Age:

Chief Complaint: Sex:
Impression / Diagnosis: Inclusive Dates of Care:
Diet: Allergies:
Type of Operation:

Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

1. Activities – Rest .

a. Activities
b. Rest
c. Sleeping Pattern

2. Nutritional – Metabolic

a. Typical Intake
(food or fluid)
b. Diet
c. Diet restriction
d. Weight
e. Medication/Supplement food
 Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

3. Elimination

a. Urine (frequency, color,

transparency)

b. Bowel (frequency, color,

transparency)

4. Ego Integrity

a. Perception of Self

b. Coping Mechanism

c. Support System

d. Mood / Affect

5. Neuro – sensory

a. Mental State
b. Condition of 5 Senses:
(sight, hearing, smell,
taste, touch)
 Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

6. Oxygenated and Vital Signs

a. Respiratory Rate
b. Pulse Rate
c. Temperature
d. Blood Pressure
e. Lung Sounds
f. History of Respiratory Problems

7. Pain Comfort

a. Pain (location, onset, intensity,

duration, associated symptoms,
aggravation)
b. Comfort Measures / Alleviation
c. Medication
Normal Pattern Before Hospitalization Clinical Appraisal

Initial Day 1 Day 2

8. Hygiene & Activities of Daily

Living

9. Sexually

a. Female (menarche, menstrual

cycle, civil status, number of
children, reproductive organ.

b. Male (circumcision, civil status,

number of children)
 DRUG STUDY

Prescribed,
Generic Name Recommended,
Brand Name Dosage, Frequency, Mechanism of Indications Contraindications Adverse Effect Nursing
Classification & Route of Action Responsibilities
Administration
 LABORATORY AND DIAGNOSTIC PROCEDURES

Name of Procedure Result Normal Value Nursing Implication

Hematology

WBC

RBC

Hematocrit

Hemoglobin

Platelets

Segmenter

Lymphocyte
 Monocyte

Eusinophils

Urinalysis

Color

Transparency

Pus Cells

RBC

Epithelial Cells

Bacteria
 LABORATORY AND DIAGNOSTIC PROCEDURES

Name of Procedure Result Normal Value Nursing Implication

 LABORATORY AND DIAGNOSTIC PROCEDURES

Name of Procedure Result Normal Value Nursing Implication

 SUMMARY OF INTRAVENOUS FLUID

Date / Time Started Intravenous Fluids & Volume Drop Rate Number of Hours Date / Time
 SUMMARY OF MEDICATION

Date / Time Medication Remarks

 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
DIAGRAM OF PATHOPHYSIOLOGY
(Actual on Patient’s Case)
 MEDICAL MANAGEMENT

IDEAL:
ACTUAL MEDICAL MANAGEMENT
NURSING MANAGEMENT
 DISCHARGE PLAN

Patients Name: Date of Discharge:

Condition upon Discharge: Nature: Home per Request ( ) Discharge Against Medical Advice ( )
MGH ( )

1. Medication

2. Exercise

3. Diet

4. Health Teaching

5. Schedule for next visit