LAXMI MEMORIAL COLLEGE OF NURSING

NURSING PROCESS APPLICATION FORMAT

II YEAR BSc NURSING

Biographic data
 Age -
 Gender -
 Sex -
 Religion -
 Education -
 Occupation -
 Income - Rs/ month
 Marital status -
 Address -
 Date of admission -
 IP no -
 Ward -
 Bed no -
 Diagnosis -
 Date of surgery -
 Name of surgery -
 Date of Discharge -
Chief Complaints
 Date of admission
 Complaints at the time of admission
 Diagnosis – provisional / diagnosis at discharge
History of present illness
 Onset – When symptoms are started / gradual / sudden
 Duration – How often the problems occurs
 Exact location of distress
 Characteristics of complaints – Intensity of pain / quality of secretion etc
 Associated symptoms –
 Factors aggravate relieve problems
 Relief measures taken
 Activity in which the client was involved when the problem occurs
Past health history
 Childhood illness (communicable disease/ any other )
 Childhood immunization
 Allergies to drugs , animals , insects, or other environmental agents
 Accidents or injuries – how / when / type of injury / treatments / complications
 Hospitalization for serious illness – reason for hospitalization / name and date of surgery
performed if any / course of recovery and any complications
 Medications if any
 Blood transfusion
Family history
 Type of family
 Relationship between members
 No of family members
 Current health status of family members
 Any resent death and reason for it
 Hereditary and communicable diseases
 Family tree
Personal history
 Personal habits – amount , frequency and duration of substance use ( alcohol . tobacco,
chewing pan , tea , coffee, chewing betel leaves )
 Diet – type of diet , no of meals and snacks per day / likes and dislikes and food allergies
 Sleep / rest pattern – hours of sleep per day / difficulty in sleeping / remedies used for that /
 Activities of daily - any difficulties in eating / grooming / dressing / elimination / locomotion
 Recreations and hobbies – exercise hobbies
Socio economic history
 Lower / middle / upper class family
 Earning members of the family / occupation
 Income per month
 Physical facilities of the house
 Community services to meet the clients need – hospital / transport communication
 Relationship with neighbors / friends

Nutritional history
 Dietary pattern – veg / non veg / mixed / amount / frequency
 Body built
 Likes and dislike
Menstrual history
 Age at menarche
  Cycle , Amount , of flow , duration
 Any discomfort
 Any medication used

Investigations

S.L No Date Name of investigation Patient value Normal value Remarks

Medications

S.L Name of Dose Route Frequenc Action

No medicatio y
n

Drug file

S. Name of Dose/ Actio Indicatio Contraindicatio Side Nurses

L medication/Gener Route/ n n n effect Responsibility
No ic name Frequenc s
y
HEAD TO FOOT PHYSICAL EXAMINATION

General appearance and behaviors

 Gender
 Signs of distress - Pain / Difficulty in breathing / Anxiety / Sleeplessness
 Body type - Trim & muscular / Obese / Excessively thin
 Posture - Slumped / Erect / bent
 Gait - Co ordinate / Un coordinate
 Body Movements - Tremors / Immobile
 Body - Pleasant / Unpleasant
 Affect and mood - Appropriate for situation/Anxious/worried/depressed
 Speech - Understandable/ Not understandable
 Substance abuse -
Vital Signs
 Temperature -
 Pulse -
 Respiration -
 Blood Pressure -
Height and weight
 Height - Cm
 Wight - Kg
Hair and Scalp
  Hair
 Color - Black / gray / white / golden
 Distribution - Normal distribution/ Unusual
 Texture - Smooth /Fine brittle / Thin /stringy
 Lubrication - Dry / excessive oily
Scalp
 Cleanliness / lesions / dandruff / pediculi
Head and neck
Head
 Position - Upright / tilted to one side
 Shape - Round / oval
 Facial features - Symmetry / asymmetry
Eyes
 Visual acuity -
 Extra ocular movements - Parallel movements / nystagmus
 Visual field -
External structures
 Position - Normal / exopthalmos / strabismus
 Eyebrow
Size
Symmetry
Texture of hair
Alignment
Movement
 Eye lids
Position
Ability to open, close and blink
Signs of infection/ ptosis/stye/chalazion
 Lacrimal apparatus - Palpable / not palpable
 Conjunctiva and sclera - Color,[transparent,red,white /yellow] / foreign bodies/
texture and lesions
 Corneas - Clarity / corneal blink reflex / lesions
 Pupil and iris - Size / shape / equality / accommodation/reaction to
light / lens
Internal eye structure
 presence of retinal lesions and detachments /appearance of fundus / macular
degeneration/clarity optic disc
Ears
  Auricles
 Ear canal and ear drums
 Hearing acuity
Nose and sinuses
 Nose
 Sinuses
Mouth and Pharynx
 Lips
 Mucosa
 Gums
 Teeth
 Tongue
 Palate
 Pharynx
Neck
 Neck muscles
 Lymph node
 Thyroid gland
 Trachea
Breast and axilla
 Inspection of the skin
 Axilla
Thorax and lungs
Anterior thorax
 Shape and symmetry of thorax
 Chest movements
 Use of accessory muscles
 Vocal fremitus
 Breathing pattern
Posterior thorax
 Symmetry / spinal alignment / back pain / CVA tenderness
- Size / shape / symmetry / position / color / tenderness
Skin lesions / discharge / structural deformities
- color / discharge / scaling / foreign bodies / ear wax /
Bulging / tear / mastoid bone tenderness
- Rinne’s test / Webbers test
- Skin color / lesions / deformity / discharge / swelling
Bleeding/ DNS / patency / polyps / turbinates /
- Inflamed / swollen / tenderness / tan illumination
- Color / texture / hydration / lesions
- Color / hydration / lesions
- Color / edema / bleeding / lesions
- Position / dental caries/ extraction sites / color /
No of missing teeth / dentures
- Color / coatings / movements /
- Color / extra bony prominence
- Gag reflex / position / edema / ulceration / inflammation
- Symmetry / movements and muscle strength
- Palpable / not palpable / enlarged
- Visible masses / symmetry / enlargement
- Location / position
- Discoloration/ hyper pigmentation / retraction / dimpling
Edema / masses / lesions / symmetry
- Lymph node –Palpable / non palpable
Abdomen
 Inspection - Skin integrity / contour / symmetry / liver and spleen
enlargement / abdominal movements / vascular pattern /
hernias / abdominal girth
 Auscultation - Bowel sounds ( hyper , absent , hypo sound )
Vascular sound, (Renal, aorta, iliac, femoral artery )
 Percussion - Percuss four quadrants / liver for dull sound, ascetics
 Palpate - Tenderness / liver / spleen / bladder
External genital organs
Females
 Infalmmation / swelling / lesions /bleeding per vagina / vaginal discharge [color, odor,
quantity]
 Palpate inguinal lymph node
Genitals (males)
 Screened for presence of inguinal hernia
 Inspect glans penis for lesions , nodules / swelling / inflammation / discharge/
 Palpate for tenderness, thickening and nodules
 Inspect scrotum for size, symmetry / deformities / size / inflammations
 Palpate both testis – hypospadiasis, epispadiasis
Rectum anus and prostate
 Color/ integrity and skin lesions
 Palpate anal sphincture / nodules / masses / tenderness
 Palpate prostate gland
Extremities
 Range of motion
 Joint swelling / deformity / crepetition
 Any muscle atrophy / asymmetry
 Muscle strength
 Involuntary movements

Reflexes
 Superficial reflexes
Corneal reflex
Gag reflex
Abdominal reflex
Plantar reflex
Babinski’s sign
Cremasteric reflex
  Deep reflex
Biceps reflex
Triceps reflex
Brachio radials reflex
Patellar reflex
Achilles tendon reflex

SYSTEM WISE EXAMINATION

Integumentary system

 Color - Pink / Brown / bluish / pallor / yellow/vitiligo/ albinism

 Moisture - Smooth and dry / excessive dryness / crusting / flaking /
excessive moisture
 Temperature - Warm / cold / clammy
 Texture - Smooth/rough/thin/thick/hard
 Turgor - Good / poor
 Vascularity - Fragile / Petechiae
 Edema - Present /Absent
 Lesions - Macules / Papules / vesicles / Wounds
Nails
 Color/cleanliness/length/thickness/angle between nails & nail bed / capillary refill
 Clubbing of nails
 Beau’s line
 Koilonychias/ paronychia [whitlow or felon]

Neurological system

Mental status
 Orientation - Time /place /person
 Mood and affect -
  Memory - Immediate/ recent/ remote
 Language - Asphasia
 LOC/ Glass gow coma scale
Cranial nerve assessment
Motor system
 Gait and station -
 Muscles - symmetry/ tone / strength
 Rombergs test -
Sensory system
 Position sensation
 Light touch
 Vibration
 Reflex

Endocrine system

 Rate of growth / Heat or cold intolerance / Changes in glove, shoe, or ring sizes / Sweating
or flushing
 Weakness / Polydipsia, polyphagia, polyuria (classic signs of diabetes) / Weight changes /
Abnormal pigmentations / Change in skin texture / Dryness of skin and hair
 Irregular menses / Impotence
 Thyroid enlargement

Cardio vascular system

 Inspection - symmetry /skin color/edema/varicose vein/jugular vein distention

Thrombophlebitis / swelling / Homan’s sign / tenderness
 Palpation - Pulse-
Peripheral pulse in the legs / arms
Rate/rhythm/force/carotid pulse/equal and bilateral
 Percussion - Sound/able to distinguish/right and left margin of heart
 Auscultation - S1,S2,S3/S3
Heart rate/pulse deficit/murmur
Apical pulse – location/ heart rate/ jugular vein distention
 Cap.refill
  Allen’s test
 Grading of edema
 Peripheral perfusion – color / temperature / edema /skin changes / cyanosis and pallor

Respiratory system

Inspection - rate/rhythm/depth/pattern
 Use of accessory muscles
 Shape and symmetry
 Movements
 Sternum
 Skin color
 Spinal curvature
Palpation
 Position of trachea
 Tactile fremitus
 Ronchial fremitus
 Thoracic excrusion
Percussion
Auscultation
 Normal and abnormal breath sound

Gastro intestinal system

Mouth
 Inspection
Lip - color/symmetry/size/lesions
Tongue - coating/lesions/color
Teeth & gums - carries/loose of teath/abnormal shape and
position/swelling/bleeding/inflammation
 Palpation - Nodules/indurations/tenderness
Abdomen
  Inspection - Skin changes
Color/texture/skin integrity/scar/striae/dialated
vein/rashes/umlicus/observable mass/abdominal movements/vascular
pattern
 Palpation - muscle resistance/tenderness/organs
 Percussion - percuss four quadrants, liverfor dull sound, ascetics
 Auscultation – bowel sounds ( hyper , absent , hypo sound )
vascular sound, ( Renal, aorta, iliac, femoral artery )
 Rectum and anus- Fistula/heamorroids/lump/color and consistency of stool
 Perineum

Urinary system

 General
Fatigue / lethergey / LOC / alertness
 Urine
Output / character [color,odour,sp.gravity] / frequency / urgency / burning sensation /
dribbling of urine / flank pain.
 Inspection
Skin - color / pallor / turgor / texture
Mouth - Stomatitis / ammonia breath
Face and extremity – Edema – generalized and localized
Masses
Weight – weight gain or loss
 Palpation – kidney size / position / tenderness / neoplasm
Bladder – fullness
 Percussion
 Auscultation – any bruit

Musculo skeletal system

 General body built

 Muscle symmetry
 Gait
 Posture
 Palpation
 Neck / shoulder / elbow / wrist / hand / back / hip / knee / ankle / feet
Tenderness / swelling
 Fasciculation / tenderness / ROM / tremor
 Crepitation / body posture / scoliosis / lordosis / kyphosis / genuvarum / genu valgum /
joint pain