St.

Paul University Philippines

Tuguegarao City, 3500
School of Health Sciences

Patient’s Initials: _______________ Age: _________ Student’s name:

________________________________
Admitting Diagnosis: _________________________ RLE Group:
____________________________________
Surgical Procedures:__________________________ Date:
_________________________________________

Assessment

Medical/ Social History:

Chief Complaint:

P
E
R
S
O
N
S
Introduction

Health History
Current Health Problems: Family risk factors:

Past Health Problems:

Surgical History:

Obstetrical History: Medications:

Accidents:

Patient education needs:

Psychosocial
Significant Others: General appearance:

Coping Mechanisms: Non-verbal bahavior:

Occupation/ education: Affect:

Primary language: Orientation:

Primary source of health: Memory:

Financial resources: Speech:

Elimination Rest and Activity

Stool: Current Activity level
 ADLs

Sleep

Urine Body Frame:

• Quantity per voiding

• Quantity per 24 hours Posture:

• Pattern
Gait:
• Color

• Specific gravity Coordination:

• Clarity
Balance:
• Laboratory analysis

Muscle:
Legs
Arms
• Strength

• Tone

Abdomen: Motor Function:

• Contour: • Fine

• Bowel Sounds: • Gross

• Percussion: Range of motion:

• Palpation: • Legs

• Arms

Toileting ability: Pain relief measures:

Mobility:

• Use of assistive devices

Nutrition Spirituality
Hospital Diet: Religion:

Religious Organizations:
Fluid Intake: Religious practices:

IVF:
• Site

• Solution:

Height:

Weight:

IBW:

Skin Turgor: Values and Beliefs:

Ability to:
• Chew

• Swallow

• Gag Reflex

• Tolerate Food:

• Nausea and vomiting:

• Feed self:

Laboratory analysis:
• Na

• Cl

• K

• Cholesterol

• Total protein

Blood glucose monitoring:

Safety Oxygenation
Allergies: Activity tolerance
• Medications Airway clearance:
• Nose
• Foods:
• Mouth
 • Environment
Eyes/ Vision Respirations
• Rate

• Use of eye glasses • Rhythm

• Use of accessory muscles

• Pupils
• Position assumed

Lung sounds

Hearing Color
• Skin

• Nails

• Lips
Skin Integrity Capillary refill time

• Lesions Pulse oximetry

Peripheral pulses
• Location
• Surgical incisions/wounds
• Rate

• Rhythm

• Strength

• Equality

Apical pulse
Mucous membranes Blood pressure
Edema
Homan’s sign
Temperature Lab analysis:
• RBC
• Route: • Hemoglobin
• Hematocrit
• Platelet count
• ABG
Laboratory analysis Oxygen therapy
• WBC

Pathophysiology
Anatomy and Physiology
 Nursing Diagnosis Defining Characteristics Expected Outcomes

P
E
R
S
O
N
S Nursing Interventions Evaluation of Expected Outcomes
M N PM
M
Allergies: _________________________________________ Allergic response:
_______________________________

1. Drug generic and Brand 1. Action/ use of each drug 1. Side effects
Name, Dose, Frequency, 2. Rationale for this 2. Nursing implications
Route, Time patient 3. Actions to be done when
2. Drug Classification administering the drug