I.

DATA BASE AND HISTORY

Name of Patient: Date of Birth: Sex: Age: _
Address:
Religion: __ Civil Status: Nationality: _
Date of Admission: ____ Time of Admission:___ ___
Informant: _____ Relation to Patient: ______ _____
Address of Informant:

Initial vital signs:

Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: __

Chief Complaints and History of Present Illness:

Has received blood in the past? Yes _____ No _____ if yes, list dates_________________

Blood reactions if any:

______________________________________________________________________________________
______________________________________________________________________________________

Allergies
Food: None
Medications: ______________None ___________

Admitting Diagnosis: _ __________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Attending Physician: __________ ________________

Consultant: _________________________________________________________

II. NURSING ASSESSMENT

A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, comfort.
Objective Subjective

11
General Appearance: □ Alert/responsive Usual Diet: __________
□ Apathetic □ Cachexia □ Abdominal Distention No. of meals per day: ___ (3x a day)
No. of fluid drink each day: (8-12 glasses/day)
□ Mass □ Tenderness/pain
Skin: □Dry □Warm □Cold □Moist □Edema
□ Alcohol and Beverages ________________________
Turgor: _____
Eyeball: □ Sunken □ Moist □Dry
Undesired Weight loss: □ Yes □ No
Mouth: □ Dentures □ Braces □ Lesions Undesired Weight gain: □ Yes □ No
□ Cleft Palate □ Cleft Lip □ Ulcers
Food restrictions R/T intolerance and health
No. of teeth:
problems or religious practices?
Tongue: □ Dry □ Moist □ Furrows _____________________________________
Difficulty in eating and swallowing:
Venous filling: __ (Normal less than 3-5 sec) ____
Intravenous Fluid: ______________
Date of insertion: ____________________________ Previous/Recent Illness:
□ Diabetic □ Hyperthyroidism □ Hypothyroidism
Wounds: ______________________________
□ Colon Cancer □ Abdominal Pain
Tube/Drainage: __None__________________ Comment:

Vital Signs:T- P- R- BP-

Elimination pattern: □ Diarrhea □ Constipation
Body Types: Frequency of BM:______/day
□ Ectomorph □ Mesomorph □ Endomorph
□ Obese □ Thin

Loss of Appetite: □ Anorexia □ Bulimia

Body weight: kg

Remarks: .
_____________________________________________________ ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Nursing Diagnosis:
_______________________________________________________________________________________
_______________________________________________________________________________________

B. RESPIRATORY SYSTEM
Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort

Objective Subjective

12
Breath Sounds: □ Diminished/Absent □ Stridor Previous/Recent Illnesses:
□ Rales/Crackles □ Rhonchi/Wheezing □ Bronchitis □ Emphysema □ Asthma
□ Normal (Vesicular, Bronchovesicular, Bronchial) □ Brochiectasis □ Pneumonia □ Hydrothorax
□ None (atelectasis) □ Pneumothorax □ Hemothorax □ CHF
□ Chest Trauma □ Lung Cancer
Resonance: □ Hyper □ Hypo Comment:
_____________________________________________
Respiration/Oxygenation:
□ Normal(Relax, Effortless and Quiet)
Breathing Treatments/Medication:
□ Labored/Use accessory Muscle] □ Dyspnea
_ _____
□ Tachypnea □ Bradypnea □ Cyanosis _____________________________________________
□ Pallor □ Cheyne-stoke □ Biot’s _____________________________________________
□ Hyperventilation □ Hypoventilation
□ Nasal Flaring □ Pursed lip □ Barrel Chest Smoking:
□ Pleuritic Pain □ Yes For how long: __________
□ O2 Inhalation _____liters/min □ No
Rate: ______________________ Comment:
Tube/Drainage: □ CTT □ Oral Airway
□ Endotracheal Tube □ Ventilator

Cough: □ Productive □ Non-productive

Sputum: □ Mucoid □ Bloody (hemoptysis)
□ Rusty □ Frothy □ Thick Tenacious
Color: ________

Remarks:
The Respiratory System is intact and no abnormalities.

Nursing Diagnosis:
_______________________________________________________________________________________
_______________________________________________________________________________________

C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.

13
Nursing Diagnosis:
_______________________________________________________________________________________
_______________________________________________________________________________________

Objective Subjective
Temperature: _____ Celsius Previous/Recent Illness:
Blood Pressure: Right _Left __ □ CVA □ CHF □ MI □ Thrombophlebitis
□ Family History of HPN □ Renal Failure
Pulses:
Carotid Pulse: □ Thready □ Weak □ Strong □ Absent
□ Bleeding Disorder __________________________
Rate: Right Left Comment:
_____________________________
Apical: □ Regular □ Irregular Rate: ____ _____________________________________________
_____________________________________________
Radial Pulse: □ Regular □ Irregular □ Thready □ Weak
□ Strong □ Absent Rate: Right Left _____________________________________________

Dorsalis Pedis: □ Regular □ Irregular □ Thready □ Weak Do you experience any of the following:
□ Strong □ Absent Rate: Right_____ Left _____
Posterior Tibia: □ Regular □ Irregular □ Thready □ Weak
□ Chest pain □ Arm pain □ Leg pain
□ Strong □ Absent Rate: Right_____ Left _____ □ Joint and Back □ Dyspnea □ Orthopnea
□ Cough □ Numbness and Tingling
Heart Rhythm: □ Tachycardia □ Bradycardia □ Light headedness □ Fatigue and weakness
□ Arrhythmia/ Dysrhythmia □ Palpitations
Comment:
Jugular Veins Distention: _____________________________________________
□ Positive □ Negative
Exercises:
Nail bed Color : □ Pink □ Blue □ Pale Type: _ ______
Frequency: _ __
Capillary Refill: ___ (Normal less than 2 sec) Duration: _______

Edema: □ Pitting □ Non Pitting Problem experience with usual activity and exercise:
Location Lower extremities (Both feet) Comment:

Factors Affecting Activity Intolerance:

Varicosities: □ Yes □ No Comment:
Location: __________________________________ __
Calf Tenderness (Homan’s Sign):
Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks:

D. INTEGUMENTARY SYSTEM
Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.
Objective Subjective

14
Skin: □ Dry □ Intact □ Warm □ Cold □ moist
Turgor: __________________________
□ Pallor □ Cyanosis □ Jaundice □ Rashes
□ Acanthosis Nigricans □ Albinism □ Erythema
□ Edema □ Petechia □ Itching □ Drainage
□ Swelling □ Wound □ Ecchymosis/hematoma
□ Decubitus Ulcer
Temperature: _______
Hair: □ Alopecia □ Hirsutism □ Patchy hair loss
Distribution: _______________
Nails: □ Dirty □ Pallor □ Cyanosis
□ Clubbing □ Paronychia □ Onycholysis
Capillary refill: _______ (Normal less than 2 sec)
Color: __________
Comment : _
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Comment:_
_____________________________________________
_____________________________________________
Comment:__
_____________________________________________
_____________________________________________
_____________________________________________

Remarks: __
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Nursing Diagnosis:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

E. ELIMINATION

Objective Subjective

15
Mobility and Dexterity: Previous/Recent Surgery/Illness: __
□ Ambulatory □ Non-ambulatory ________________________
□ Bedridden □ with assistive device
History of pain and discomfort:
Tubes/Drainage/Stoma: _____________________________________________
□ Colostomy □ Ileostomy □ NGT
Diet: ________
□ Catheter □ Suprapubic Catheter
Personal Elimination Habits: ___
Abdomen: □ Soft □ Firm _____________________________________________
□ Distended □ Non-distended
Elimination Problem:
Bowel Sounds: (5 – 20 sounds/min) □ Loose bowel movement _________
□ Normoactive □ Hypoactive □ Constipation □ Impaction □ Fecal Incontinence
□ Hyperactive(Borborygmi) □ Absent □ Neurologic Impairment □ Dysuria □ Urgency
□ Polyuria □ Oliguria □ Nocturia □ Dribbling
Measurement:
□ Incontinence □ Hematuria □ Retention
Intake ____________ Output:_______________
□ Discharge
Edema: □ Yes □ No □ Residual urine (> 100ml)
Location: __ ________ Comment: ___________________________________
_____________________________________________
Present Urine Color: _ _
Medication taken: □ Analgesic Narcotic
Note: Assess urine frequency, color, odor control, □ Antibiotics □ Anticholinergic □ NSAID
comfort/gyn-bleeding, discharge. □ Aspirin □ H2 antagonist
Comment: __________________________________ Fluid intake per day: __ liters/day
___________________________________________
___________________________________________ Physical Activity: ____________________
___________________________________________ Comment:_____
___________________________________________ _____________________________________________
___________________________________________ Excessive Perspiration and Odor Problem:
___________________________________________ □ Yes □ No
___________________________________________
Consistency:
Stools:

Remarks:
__________________________________________________________________________________________
__________________________________________________________________________________________

Nursing Diagnosis:

F. MUSCULOSKELETAL SYSTEM
Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, comfort.
Objective Subjective

16
Mobility: □ Ambulatory □ Non Ambulatory Do you experience any of the following:
□ Bedridden □ Lumbar pain □ Thoracic Pain □ Cervical Pain
□ Appliance ___________________________ □ Joint pain
Gait and Posture: □ Lordosis □ Kyphosis Comment
_____________________________________________
□ Scoliosis □ Shaftling □ Poliomyelitis
□ Amputated Limb ______________________
Club foot (Talipes)
□ Varus □ Valgus □ Equinovarus □ Calcanous

□ Use of Appliance __________________________

Muscle Tone/Strength:
□ Normal □ Slight weakness
□ Average weakness □ Poor ROM
□ Severe Weakness □ Paralysis
□ Atrophy □ Hyperatrophy
□ Spasm

Abnormal Findings:
□ Impaired ROM □ Joint swelling ____________
□ Contractures/Deformities □ Crepitus
□ Tingling/Numbness (Carpal Tunnel Syndrome)
□ Ankylosis □ Foot Drop □ Pressure Ulcers
□ Urinary Elimination changes _________________

Calf Tenderness (Homan’s Sign):

Right □ Positive □ Negative
Left □ Positive □ Negative

Remarks:

__________________________________________________________________________________________
__________________________________________________________________________________________

Nursing Diagnosis:
____________________________

G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

Note:
Objective Subjective

17
LOC: □ Alert □ Lethargic □ Comatose Do you experience any of the following:
□ Unresponsive □ Blurring □ Diplopia □ Photophobia
Orientation: □ Person □ Place □Time/Date □ pain □ Inflammation □ Cataract
□ Pain □ Glaucoma □ Headache □ Unusual Discharges
Comment:

Remarks:

__________________________________________________________________________________________
__________________________________________________________________________________________

Nursing Diagnosis:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

HEALTH TEACHINGS

18
 Medications:

Exercise:

Treatment:

Out patient (Check

up)

Diet:

19