apo 21wapDoy LUN sauapMs 2a - “eINyDUBIS 5,951 ~ TUORDBAFEAU| suonueni9qut qo pup | uonoun qunowy | adfy | qunowy | adfy | 24d | uonpudsoy | asing | UnmvedwaL Burn | spowey | Y*PEN| sinpasoig | jomog pooig ‘poq | euyewa >psoubpig qehno ping | _Saew PM TUBE Ba ‘ON fpudio -~ “ssausnopsuod Jo jana — “fayngon Jo [ano — 'SISOUBDIP [D>1Pa/\ - Ip 2anadpseyy - “oN Wooy — jen9| DUCRDONpy - epusg — By - ‘@Cuponuapyuor upyuroul 07 Ao auubu 218uaD) ‘LIDU squaRAdd - JOISSILUPD Jo 230Q, SaION Sjuapms BuIsiNNRespiratory Rate Temperature Blood Pressure Score Systolic BP Tate wih TRE navearied out Conscious level Total Score:Nursing Assessment Sheet - Patient's Sociodemographic Data ~ Patient’s name: (Generic name only to maintain confidentiality): ~ Gender: -Male( ) -Female( ) Hospital No. - Age: ~ Department: = Bed No. summmnanananie = ROOM NO, snsnsnsnnnn ~ Date Of AAMISSION: snansnneninnnnnnnnananannn ~ Pattern of admission. ~ Private physician ( ) Outpatient clinic ( ) Emergency unit ( ) — Level of consciousness: Conscious ( ) — Semi-conscious C) Unconscious C) ~ Level of acti Active (Active assistive ©) Bed ridden ©) ~ Marital status: Single ( ) Married ( ) Divorced( )Widow( ) = Occupation: Manual Work () Housewife ( ) Retired o) Not Working = (-) Clerical Work. ©) - Educational level: literate () Can read and write ( ) Primary ( ) Secondary ( ) University () ~ Area of residence: Rural( ) Urban( ) - Therapeutic diet = Medical diagnosis: = Diagnosi = Name of operation: .nmmnmnmmnmnnnmnnnnnnminnnnnnnnnninninnnnnnnannnnnnnennn "Date of operatior = Postoperative days: > Health history: 2. Reason for Hospitalization: ..nmnimnninnnininninninnnnnnninnnnnnnnnnnnnnnnnns Location: Duration: Aggravating factors: Alleviating factors: v v Y Onset: Sudden( ) Gradual( v v v Associated factors:Medication: - Prescribed No Yes - Over the counter No Yes Smot - Smoker No Yes - Passive smoker - Quitter No Yes No Yes Alcohol intake: No Yes = Frequency (.nmmnmmnene meals/clay) - Likes and dislikes - Amount of fi fake _Liday ‘Ordinary) -Therapet If therapeutic specify. Nutrition: - Dietary intake: Item Please circle If (yes) Specify Past history Previous hospitalization No Yes Associated diseases No Yes Previous surgery No. Yes Allergies No Yes Previous blood No Yes Type__Amount _Time _ transfusion Family history Cancer No Yes Hypertension No Yes Diabetes Mellitus No Yes Kidney disease No Yes Asthma No Yes Heart disease No Yes Liver disease No Yes Others No YesLifestyle/health patterns/habits Elimination Sleep Level of activity: Bowel frequency: IDay Constipation () Diarrhea () Others Urinary frequency: [Day Attached urinary catheter Yes ©) Voiding pattern One () Reluctant stream Dripping (.) Others () Specify Pain Yes O) No q) Ifyes Suprapubic = (.) Flank Incontinence ( ) Others Amount Normal (.) — Polyuria Oliguria O Anuria () Nocturia O) Pyuria @) Hematuria O) Retention Dysuria O) = Sleep hours: Day During night Independent (active) QO Partial independent (active assistive) QO Dependent (Bedridden) QO Q) No C) O) O) O) Specify QO) Specify> Physical Examination: Head Face Item Amount and distribution of hair Presence of lice Presence of dandruff Scalp Others Color Eye Vision Color Others Ear Hearing Presence of discharge Others Nose Patency Position of nasal septum Smile Others Mouth Lips Mucus membrane Teeth ‘Odor Tongue Please circle Normal Abnormal No Ves No Yes Intact Not intact No Yes Healthy Unhealthy Normal Impaired Normal Abnormal No Yes Normal Impaired No Yes No Yes Not- Patent patent Normal Abnormal Normal Abnormal No Yes Normal Abnormal Normal Abnormal Intact Lost Absent Present Normal Abnormal If (yes) Specify Brittle Alopecia Scratches, Lesions__ Pale ___Cyanotic Yellow Prosthesis RIL. Prosthesis__ RIL Moist Dry__ Cracked __ Ulcers___Patches__Dry__ Bleeding__ Denture__ Ulcers__ Coated_Dry_Head Item ‘Amount and distribution of hair Presence of lice Presence of dandruff Scalp Others Neck Inspection Jugular veins Position of trachea Old scar Palpation Lump, Swelling Lymph node Manipulation Range of motion Others Please circle If (es) Specify Normal Present Present Present Free Yes Abnormal Brittle Alopecia, Yes Yes Not intact Scratches__Lesions_ Yes Congested Deviated Absent Absent Absent Limited No YesChest ‘Abdomen Item Inspection - Shape of chest wall ~ Chest movements ~ Using of accessory muscles - Others Palpation ~ Chest expansion - Tenderness - Lumps Tactile fremitus sound - Others Percussion ~ Percussion sound Auscultation - Air entry ~ Breath sounds ~ Apical pulse - Others Inspection - Shape - Skin integrity Auscultation - Bowel sounds Palpation - Tenderness - Lump - Distention Percussion Please circle If (yes) Specify Barrel___ Kyphosis__ Normal Abnormal Funnel___ Pigeon, Equal Unequal No Yes No Yes Equal Unequal No Yes No Yes Normal Abnormal No Yes Flatness__ Dullness__ Resonant Abnormal Hyper resonant__ Tympany. Bronchial vascular Bil-equal Diminished bronco vascular Wheezing___ Crackles Normal Abnormal Rhonchi Rate Rhythm Chest pain__ Cough, No Yes Pain— Cough — Dyspnea_ Distension _Ascites, Normal Abnormal Hernia. Intact Abnormal Scars___ Rashes Present, Hypoactive, Hyperactive Absent__ Present. Absent__ Present___ Absent__ Present___ Absent__ Present. Absent__ Present. Absent__Upper & Lower Extremities Lymph Nodes Peripheral Pulse -Duliness --Tympanic - Others Inspection Skin color Skin integrity Skin temp. Varicose veins Nail color Nail shape Palpation Skin turgor Sensation Edema Capillary refill Manipulation Joints Others Cervical Axillary Femoral Temporal Carotid Brachial Radial Femoral Popliteal Posterior Tibial No Normal Intact Warm Yes Normal Normal Elastic Normal No < 35sec Free No Non palpable Non palpable Non palpable Present Present Present Present Present Present Present Yes Abnormal Abnormal Abnormal No Abnormal Abnormal Inelastic Abnormal Yes Abnormal Limited Yes Palpable Palpable Palpable Absent Absent Absent Absent Absent Absent Absent Anorexia Pain___ Nausea __ Constipation _ Incontinence_ Cyanosis___ Pale, Yellowish, Scars___Lesion_ Hot __Cool___ Moist__ Site Clubbing ~ Paresthesia___ Numbness _ Site Type Degree >3sec Swelling Deformed_ Redness__Dorsalis pedis Present Absent Psychological status ~Fear( ) *cooperative() — *Passive()_ * Active ( ) * Aggressive ( ) -Sleep : *Normal() *Altered ( ) If yes specity.. Manner of communication: “Talks freely) *Reluctant() —* others ()suonuenieay, . suonuanseyu . ; ze Uonueneid fed plBpudrg —juausojduy} ost ss mo uaap * Co 0 Bunn 3904 Poe we-0 son monian ©) ony ‘31095 SW Teno STE 1230, ‘SHORE YUN JO [}WBIO} eq 0} PUD seAILIGD UMO JOU/SIY S{DUIRSEIOAS sr St | 03 pasepsucs 51 quand ay uatR ‘sAs}OaIUN 5 asuodser squaADd AUR J! 10 SIepIO BUIsANU O43 Yalm qWHEYsISUOD yOu s} asuodse1 squaRE Up J] 0197 | $0 payps 5] queHod 343 “seps0 AuoyINquID 349 LRM JUBys|UOD 5} MIGD UMO Jay 40 sy BUIBPN Ajde4 sqUaRD AMPA AN oz oz quenod ay pup yoys ap says “e>uDjog Gulso] jnoyym BuYIOM afiye poay auf Yi] UOD Inq Pedooys 51 quaROd eyL | —_BUNEJSUDIL/IOD “Ss oF "W068 Demy on Woy you BUPPUN PUD apr ayy Meas BUIGUINT RAND "pare poaY UM GuIeIOM waREd aly Aq pazLeDoIoW 7 Hos ulou y oa [ez Punt wo] ude 04 ABIDE OUENDA UD OY WORT BA) ear any y [owz | ON | oe “Yodan 19) aungiuany 249 oqo BuNPaNP seyDINquID qwaREd ou, #1 “JeH9m 19 79UD) IDA BUF = oy ot “#91 poq aye\duoy» pro Arownquiy ‘€ ‘Hpwpjeaye » Busr« onz “(eau b Aq peysss0 9 wana) plo Bunyjom © ynoqM s|JOM eR OYA 4 ‘si st [UbIP squeHIOd 9y9 Uo Peds 5 ANOUBOIP [O2IPOU SU UELA SHOWN so puonos z onz oN. a Le "GROUT BORA FET HIB] HRBIENAYA Jo AEN B OM BIR 9 VETTE HUSCY WATEIE BWA BUUMP UOTEI UWP | Ganoy 19 aca 4 oz “Uayjo}30U soy eR OAR BuLOSS | 31095 wey “Buje JoasH § ERE w Buysse 40) posM 5] (S4W) aE [ed PHIOW PHLquewubissy Apnig ese9 BulsinN, $749 LZ Bed ‘Capeds) 29490 = ‘OBDHON IN © ‘ery © verpomiad + smug eaprodmuness| ouuwon corn © mgd © spo rae 0 conuioat eancrnos wigs, ups ex oyun funcig Mowndeg) | 2091'7 Sunibos ge a suggenii| suing) fg ouroange “@snoup 0} Ase Asmoug L += Muoyoudsoy + eu ue AynDD, quay IULEAU| [> Bunooyse | ‘Buyunge 9702$ YdDID > isa 9 agony Oe povopes © aspire fosdyg +) somone uae Bunpye spas Bou oni “p04 og woes ee ee ee moe sug ane Pee uF 40) 0 a0, munis 01095 oimpung org oye oud “STR tany euponandoy OMRNPDHL JMO. weno Yee By TeuPN| bd eurnl_onepes _ohonpy _wone>BON | YesuON un | wea ay wee a noH way oe © RW 22pu2p “aquUN piod8y OAM qUaLUSsassDaY PUD JUALUSsassY UDGNB: If pain Score >3 Notify physician Adult Pain Assessment Scales Visual Analog Scale Word Descriptor Scale t +——t t No Mild Moderate Severe = Very Worst ratlin ns pan pan pein Pain severe ple || ° = Nova pain pain 1 = Mild pain +++ + +4 2s Daerah 0123 4567 8 9 10 3. = Severepain No Nodlerate Worst 4 = Hobe pain Ld a na 5 = Breructing pain No Worst pain possibe pain Graphic Scale Verbal Scale "Onascaleof0to 10, with AN fo for. Omeaning nopainand 10 & @ % ® ‘s g ‘meaning the worst pain you MDTINOANG can imagine how much pain are you having now?” Functional Pain Scale 0 = Nopain 1 = Tolerable and pain does not prevent any activities 2 = Tolerable and pain prevents some actvties 3 = Intolerable and pain does not prevent use of telephone, TV viewing, or reading 4 = Intolerable and pain prevents use of telephone, TV viewing, or reading 5, = Intolerable and pain prevents verbal communication Page 22 of 25 Nursing Case Study AssignmentquewuBissy Apnig ese9 Bulsiny $7 40 £7 aBed ys YBIY Aoyy» OF UOLA 495507] 29S YBIH « #1 OL uoamyag su winipayy = 8 -p1 ueomag YSU Ao" = BL UBLA 189001 Tse pus AUNT | [oz Gouna | @ Z| Oo “BUN Ij Pq dtp UO eanHFaIe ApOG PIONY BI € puowwg | 8S O “FeouaUTUIOId Fuoq sone sar peuEppal Gs 3uOd Lt v Suen 5 “paqibieid so wORS] Buh Gna wpEq p WeREd ayy Buln Aq UDG al An Molo t qo, ‘paquoieid #9 #0010 Payuay Aen, 5 Oo “auanOd Asu-YBIN |e 104 fowaROU! AIO asf) = pempdu puss |S O “PaYPIeAS PUD UEP suEUH Goay "EL ¥ 1a < “woReredeo> ope © | ups pun oinsso 0} uorisod Sui6uyp usym quand Ip YUM eyoruNWIWUES t woipeg Oo “(UoROW Jo 26uDy) enmDD sepa doayy z puneq HUD z jonpInPY m 8 © _| aun yy 03 (edo1 03 poysono 40g b) azadosy © 40 yoays Mosp D sD Yons sOrIN—P aA £ | deymetom | & "UBB AG O | 6q posopio asmioyyo stalun ajqussod jane] ysomo] aip 3D peq aif Jo Pooy ayy doo) “6 ’ jwenquy O° “punom eup uo “pDeuip 40 diy soy/sY UO quERDA atp eDDId 3,ue S| v snosodinas z z © _| pectoys anuop 28n 3,uoq ‘290 /d ul onpinypul exp deey{o3 SuIppod woos puD smoyid esp) *Z z Pesmyuod a pip Bul wey 8 © _| ancy 1 é1ene pup peq uy uaym sunoy z Arena pabuDy> 2q Pinoys UORIsod sauaREd ay “9 £ anewnedy a “sD 40 poay a z © _| smoqye ‘sey atp uo sunstosd 3nd 3,uss0p 3019 Uo sod © Ul al] 4036 Pinoys juanod aul. “s , Helv 5 O° “yeouauuioud fog s9ne eunssoid eyoine||p 0} WweREA WORIed “b : eq 419A . oO *AUBUIENOU jemog PUD UORDUUN j0UOD 03 Aygo squenod ain jo yy deoy “Ee z Poa 3 = “spn ap. ae © | seo pun say0m jo Aquald yuUp pun spoo} Ayyooy Jo AqUa!d 09 pINoYs aod B4yL -Z £ d $8 ("90 “Zip pub Ubep UR WaREM exp deay Tt 7 OOD, [[aweg jORADTaIg IN amnHeld | SUL | I OIE war TOO] qUOLUSTOSNY BAe UORON ON 2uapEry ~ LUDN squePMS, & 8 2 MAqUUNN p10D2y [21Pa. OWION saue!Dd JUOUISsessy YsIy J8D]7] auNssedg (©) ayoureg (_) 210/N 2puEDLaboratory & Diagnostic findings: ‘Abnormal laboratory studies Name of test value Name of test value Diagnostic studies Name Date Result List of patient health problems ‘Actual health problems Problems Related nursing diagnosis Potential health problems Problems Related nursing diagnosis ‘Current Medications: Name Dose Route Frequenc Name Dose | Route | Frequency Ni Page 24 of 25 lursing Case Study AssignmentquewuBissy Apnig aseg Bulsiny $2 30 $z eBeq rdnoip poy 2Weppoy {QW s4uepMaS WORONIDAR WoRUSATEAU] BUINN ¥aUIODINO] SOARPAIGO "SOUBDIQ BUISINN [UB|qoIg AUEADG "ON [oudsoH saUSNOIDsUO Jo jena] — “~* 1D Jo Janay — Rap 2pnadoieyy - “ “oN wooy - ~ uaunindag - pednoo9, aby - JUpD Jo 230g - Udjq aub9 Bulsiny