I.

Objectives
A. General
B. Specific
II.Introduction
III.Patient’s Profile
. Demographic Data
A. Chief Complaint
B. History of Present Illness
C. History of Past Illness
D. History of Family Illness
E. Social History
F. Allergies
G. Assessment
1. Physical Assessment
2. Gordon’s Functional Health Pattern
IV.Anatomy and Physiology
V.Pathophysiology
VI.Diagnostic Procedures and Laboratory Examinations
VII.Drug Study
VIII. Nursing Theory
IX.Nursing Care Management
X.Discharge Plan

XI.Bibliography
III. Patient’s Profile

A. Demographic Data of the Patient

Name:

Age:

Sex:

Address:

Civil Status:

Occupation:

Nationality:

Religion:

Date and Time of Admission:

Admitting Diagnosis:

B. Chief Complaint + (s/s of pt during admission)

(+) ______________

(+) _______________

C. History of Present Illness

Pt claimed _______________________________
D. History of Past Illness

G1: 2015, abortion

(+) UTI

F. History of Family Illness

(+) HTN

G. Social History

Pt ate junk food in the past but did not smoke or drink alcohol

Pt is a graduate, saleslady, living in; 39 y/o construction worker

H. Assessment

1. Physical Assessment

GENERAL
APPEARANCE:

VITAL SIGNS: Hospital day:

4PM 8PM
PR: PR:
RR: RR:
T: T:
BP: BP:

SKIN: No signs of edema but paleness.

LYMPH NODES: No lumps and tenderness.

HEAD: Normocephalic, symmetrical in shape without lesions

EYES: Pink palpebral conjunctivae, pupils equal, round, reactive to light and
accommodation (PERRLA)

EARS: External ear canals clear without redness, swelling, or lesions

NOSE: Nares patent, no sinus tenderness present

MOUTH: Lips dry, oral mucosa and gingiva mucosa and tongue pink without lesions

THROAT: Positive swallowing reflex

NECK: Neck movement coordinated, no difficulty in moving, no lumps and

tenderness

BACK: No spinal curvatures

THORAX: No masses or tenderness

LUNGS: Clear breath sounds, no retractions

BREAST: Round in shape, no lumps or masses

 HEART: Normal rate and rhythm, no murmurs

ABDOMEN: Flabby, normal active bowel sounds, tender hypogastric area

EXTREMITIES: No varicose veins at lower extremities, no signs of swelling at lower and

upper extremities

MUSCULOSKELETAL: Slight movement of upper and lower extremities

NEUROLOGIC: Responsive to questions

2. Gordon’s Functional Health Pattern (Verbalized by pt, use “”)

Date:
Temperature: Route: Axillary
Pulse Rate: Site: Apical
Respiration Rate:

GORDON’S FUNCTIONAL HEALTH PATTERN

Before Hospitalization During Hospitalization

Health Perception and Management

Nutritional and Metabolic

 Elimination

Bladder: Bladder:

Bowel: Bowel:

Activity and Exercise

Sleep and Rest

Cognitive - Perception

Role and Relationship

 Coping Stress Tolerance

Value - Belief Pattern

IV. Anatomy and Physiology

V. Pathophysiology

(S/s for the pt)

VI. Diagnostic Procedure and Laboratory Examination

VII. Drug Study

(List down the drugs)

NCP

Assessment Diagnosis Planning Intervention Evaluation

Subjective Short Term Dependent Goals were

“” At the end of the halfway/fully met.
shift, the patient
will: Patient was still
undergoing nursing care
as she continues to
comply to prescribed
Objective Independent medication.

Long Term
After 2 days, the Collaborative
patient will: