Duty Week:

Student Name: Date of Duty:

Clinical Instructor: Block: Area:

PATIENT INFORMATION

Name: Room Date of Admission: Date of Discharge:

Number:

Age: Sex: Civil Status: Occupation: Attending Physician:

Chief Complaints: Initial Impression:

Diagnosis (If Available)

CASE DESCRIPTION

History of Present Illness:

Past Medical History: Family Medical History:

Significant Assessment and Laboratory Finding: Diagnostic Procedure:

Findings:
 Identification and Prioritization of Nursing Problem
1.
2.
3.
4

Health Perception /Health Management Pattern

1. Chief Complaints_______________
2. What treatment/medications are you receiving___________________
3. What is your understanding of the purpose of the treatment is working?
_______________
4. Have you ever been hospitalized before for what reasons?___________________ _
5. What expectations do you have from this hospitalization?___ _________
6. What do you do to keep yourself healthy?_____________________
7. Any maintenance medication?(for chronic illnesses)_______________
8. What do you usually do when you get sick?_______________________
9. How often do you usually see a doctor for consultation?________________

Nutrition and Metabolic Pattern

1. Ht.____Wt____
2. How is your appetite?( )Poor( )Fair( )Good
3. Describe what you eat in a typical day for meals and snack (eating
Habits)____________________
4. Do you have any food restrictions or special diet due to allergies, food intolerance, other
health problems or religious practices? _________________________
5. What vitamins or supplements do you take?_________________________
6. What are your favorite foods? ____________________________
dislikes? _________________________
7. How often do you go to fast food restaurants?__________________
8. Do you experienced discomfort in eating and swallowing?
____________________________
9. Do you have dental problems? ___________________________
 10. Describe your daily fluid intake:
kind: ____________________
amount: _________________
frequency:________________

Elimination Pattern
1. What is your bowel movement pattern? ___________________________
2. Have you experienced the following?
__ constipation __diarrhea __flatulence __ileostomy __colostomy __none
3. How is your urinary elimination pattern? Which of the following do you experience?
__ incontinence __dysuria __burning sensation __ dribbling __nocturia __oliguria
__polyuria
__ urinary retention __catheter
4. Do you have any of the following skin problems?
__ dryness __ poor skin turgor __ rashes __ lesions __ itching __ swelling __ acne
__ temperature change
5. Do you sweat a lot? __ do you experience any odor problems? ________________
Activity/Exercise Pattern
1. Describe a typical day's activity ___________________________
2. What are the usual leisure activities? __________________________
3. Do you have a regular exercise pattern? ___If Yes what type? ____________
frequency? _________________ Intensity ______________ duration ____________
4. Describe any problem you have experienced with usual activity and exercise
________________________________________________________________
5. Do you experience any of the following? ___chestpain ___arm pain_
___leg pain_joint, muscle & back pain___ difficulty in breathing (dyspnea, wheezing,
orthopnea) ___Cough ___Numbness/tingling __Lightheadedness
___ Fatigue/weakness ___ Palpitations
6. Factors affecting activity of daily living __________________
Do you smoke? _________ If yes, How many packs per day? Per year? ___________
7. Do you drink alcoholic beverages? If yes, Amount ___ Frequency ___
8. Length of present hospitalization _____ Amount of time out of bed per day (if
applicable)

Sleep/ Rest Pattern

1. Time of arising ____ time of retiring ____ do you take a nap? If yes, How long?
________ How often?________________________
2. Average sleeping hours/day ______________________
 3. In general, do you feel rested and ready for the daily activities after sleep?
______________
4. Do you have aids to help you sleep? If Yes, what? ____________________________
5. Do you have nightmares? ________________ If yes, How often?
______________________
6. Do you have difficulty sleeping? ______________ If yes, how often? _______________

15G Clinic k'eas Endorse Loy Sheet

O1 September 2015 Cognitive/Perceptual Pattern
1. Eyes and vision: last eye examination? ____________________________
result _______________ do you experience blurring? ________________ Diplopia
____________
Pain ___ Inflammation ___ Cataract ___ Glaucoma __ Headache ___ Photophobia ___
Unusual discharges ____ Describe them __________________________
2. Ears and Hearing: Limitation____ Pain ___ Tinnitus ____ Describe discharges
____________
3. Other special senses: Any problems with ability to feel pain ______a ability to feel
temperature changes _________ ability to distinguish object by touch _______ ability to
smell ___________ ability to taste ___________
4. Pain: Are you experiencing pain? _________ If yes, describe _________ How does pain
affect your daily activities? ________
5. How do you cope with pain?________

Self-perception Pattern
1. How do you feel about yourself most of the time? ___________
2. Is there anything about yourself or your appearance you would like to change?
__________
3. How has your illness affected the way you feel about yourself or your body?__________
4. What things make you anxious?_______ Distressed? _______ Angry? _______
5. What do you do to alleviate this feelings?_________

Role/Relationship Pattern
1. Who do you live with?__________
2. Describe your family setting and structure?__________
3. Who makes decisions in your family? __________
4. Who do you turn to for help? ____________
5. Do family members depend on you financial needs and in the home? ___________ How
are they managing while you are ill? ____________
6. How has your health status affected your relationship with others? (family, friends, co-
workers)? ____________________
 7. What feelings have family members and friends expressed about your illness or
hospitalization? ____________

Sexual/Reproductive Pattern
1. Are you sexually active? ___________
2. Is/Are your sexual relationships satisfying? _____ Have any changes or problems taken
place with these relationships? ____________]
3. What method of contraceptives are you using? ___________
4. Do you have any problems using contraceptives? ____________
5. When was the last menstrual period (LMP)?_______________
6. Do you have any of the following menstrual problems? Amenorrhea __Dysmenorrhea
___Profuse menstruation ___ Irregular menstruation ____
7. When was your last pap smear? ______
8. Do you perform breast self-examination? __________
9. Do you give the history of miscarriage? ______ If yes, describe ___________
10. 10. Are you currently pregnant? ______________
11. Do you have a history of miscarriage? _______if yes, how many_____
12. Do you perform testicular examinations? _______
13. Do you have prostate problems? ____ If yes, describe _________
14. Have you ever had infections of the reproductive tract? _____ How frequent?
_____________________ss

Coping/Stress Management Pattern

1. What major changes/losses have you experienced in the past
2. years?_______________
3. Situations that caused stress in the past__________________
4. SItuations that cause stress in the present__________________
5. How does stressful situations affected you?__________________
6. How do you relieve tension and deal with stress?________________
7. How do you usually solve your problems?___________________
8. Have you engaged yourself into drugs, alcohol and smoking as your way of coping?
_________________
9. Who do you turn to for help during a personal crisis?___________________
10. Are you able to handle problems successfully most of the time?_________________

Value/Belief Pattern
1. What are the most Important things to you?_____________________
2. What is the role of religion in your life?_________________
3. Do you believe in superstitions?_______________
4. How does personal belief affect your health condition?________________
5. Do you generally get what you want in life? _____what are your plans for the. future?
____________
6. Do you find prayer and meditation helpful? __________________
7. Has being sick affected your belief in your religion or God?______________
 ___________________________
Date and Time of Interview

_____________________________
Student’s Name and Signature

Developmental Tasks (Havighurst, Erickson, Freud, Piaget Kohlberg Fowlers). Include only those that
are applicable,with reference. Analyze whether the patient's developmental tasks have been met or
unresolved.
Discharge Planning (METHODS - Medication, Exercise, Treatment/Therapy, Health Teachings,
Outpatient Follow-up, Diet, and Spiritual/Sexual Activity If
applicable.)
Pathophysiology Diagram

Pathophysiology Narrative
Includes but not limited to description of disease, risk and predisposing factors and signs and symptoms.
Description of normal physiology may also be discussed very briefly.
 Drug Study (5 Medications) Complete 5 Medications, if your patient has less than 5, Include any drugs with different classification
that are related to your client’s drug

Drug Appropriate Drug Nursing Implication Nursing Intervention / Why is the client
(Generic/Brand dosage for 24 Classification 1. What do you considerations related to receiving the drug based
Name), Dosage, hours, drug and Action need to check effects of drugs on history of present
Route, Frequency computation. or do prior to illness?
drug
administration
2. Major side
effects of
drugs?
 SUMMARY OF THE PATIENT’S CONDITION DURING YOUR DUTY WEEK

Day 1

Day 2

Day 3

LEARNING EXPERIENCE SUMMARY: What did your learn this week

 NURSING CARE PLAN
(Minimum of 3 problems with 5 interventions each)
Nursing Problem NURSING OBJECTIVES NURSING INTERVENTIONS Rationale of EVALUATION
with Cues DIAGNOSIS (SMART) Interventions
(Subjective and (with Reference)
Objective)