askep form

8/11/2019 askep form

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FORM D

REPORT OF PRACTICAL EXPERIENCE

I. Demographic Data

Pt. Name : _________________________________________________________________

Room/ Bed # : _________________________________________________________________

Medical Record # : _______________________

Age : year(s) month(s) week(s) day(s)

Gender : male female

Marital status : single married divorced

Address : _________________________________________________________________

Occupation : _________________________________________________________________

Religion : ______________________

Medical Diagnosis : _________________________________________________________________

Physician Name : dr.___________________

II. Definition of Disease**

Reference(s):

III. Etiology*

Reference(s):

Name:___________________

Submit Date:___________________

Week:___________________

Department:___________________

*must be with references**must be with at leasttworeferences


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IV. Signs and Symptoms*

Signs and Symptoms Theoretical Practical

V. Pathophysiology*

*must be with references


3/12

VI. Assessment

A. Health History

1. Chief Complaints (PQRST)

P :

Q :

R :

S :

T :

2. History of Present Illness

3.

Past History

a. Childhood Illness :

b. Accident(s)

i.

Type :

ii.Date/month/year :

c. Allergy :

d. Hospitalization(s)

i.Cause(s) :

ii.

Date/month/year :

e. Medications :

4. Family History (3 Generations Genogram) Legend:

= Female

= Male

= Dead Female

= Dead Male

= Pt (male)

= Pt (female)

= Divorced

= Twin

= Adopted


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5. Lifestyle

LIFESTYLE PAST PRESENT

Diet Pattern

Food Amount :

Frequency :

Contents :

Others (specify):

Amount :

Frequency :

Contents :

Others (specify):Nursing Dx. Imbalanced Nutrition : More than body requirements

Imbalanced Nutrition : Less than body requirements

Others : ____________________________________________________________________________

Liquid Amount :

Frequency :

Contents :

Others (specify):

Amount :

Frequency :

Contents :

Others (specify):

Nursing Dx. Deficient Fluid Volume

Excessive Fluid Volume

Others : ____________________________________________________________________________

Sleep and

Rest Pattern

Average sleep duration:

Sleep quality:

Sleep well Frequently awakened (__x)

Sleeping position : _____ ______ pillows

Supine Semi Fowlers High Fowlers

Others (specify)____________

Average sleep duration:

Sleep quality:

Sleep well Frequently awakened (__x)

Sleeping position : _____ ______ pillows

Supine Semi Fowlers High Fowlers

Others (specify)____________

Nursing Dx. Disturbed Sleep Pattern

Others : ____________________________________________________________________________

Elimination Pattern

Bowel Amount :

Frequency :

Consistency :

Others (specify):

Amount :

Frequency :

Consistency :

Others (specify):

Nursing Dx. Constipation

Diarrhea

Bowel Incontinence

Others : ____________________________________________________________________________

Urination Amount : Frequency :Color : Odor :

Nocturia Bladder Distention

Amount : Frequency :

Color : Odor :

Nocturia Bladder Distention

Nursing Dx. Urinary Incontinence

Others : ____________________________________________________________________________

Activities of

Daily Livings

Fulfilled independently

Fulfilled with assistance

Fulfilled independently

Fulfilled with assistance

Nursing Dx. Activity Intolerance

Others : ____________________________________________________________________________

Hobbies andRecreation

Type :_____________x/week

Type :_____________x/week

Nursing Dx. Activity Intolerance

Others : ____________________________________________________________________________


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B. Physical Examination

1.Vital Signs

T : ___C P :___x/m R :___x/m BP: ____mmHg Weight: _____kg

Nursing Diagnoses:

Hypothermia

Hyperthermia

2. Glasgow Coma Scale and Level of Consciousness

PPAARRAAMMEETTEERR FFIINNDDIINNGG SSCCOORREE

EEyyeeooppeenniinngg SSppoonnttaanneeoouussllyy 44TToossppeeeecchh 33

TTooppaaiinn 22DDoonnoottooppeenn 11

BBeessttvveerrbbaall

rreessppoonnssee

OOrriieenntteedd 55

CCoonnffuusseedd 44

IInnaapppprroopprriiaatteessppeeeecchh 33IInnccoommpprreehheennssiibblleessoouunnddss 22

NNoovveerrbbaalliizzaattiioonn 11

BBeessttmmoottoorr

rreessppoonnssee

OObbeeyyssccoommmmaanndd 66LLooccaalliizzeessppaaiinn 55

WWiitthhddrraawwssffrroommppaaiinn 44AAbbnnoorrmmaallfflleexxiioonn 33

AAbbnnoorrmmaalleexxtteennssiioonn 22

NNoommoottoorrrreessppoonnssee 11

IInntteerrpprreettaattiioonn::BBeessttssccoorree==1155;;ddeeeeppccoommaa==33;;77oorrlleessss

ggeenneerraallllyyiinnddiiccaatteessccoommaa;;cchhaannggeessffrroommbbaasseelliinneeaarree

mmoossttiimmppoorrttaanntt..

Level of Consciousness :

Compos Mentis Apathy Somnolence Stuppor Coma

Nursing Diagnoses:

Deficient Fluid Volume

Imbalanced Nutrition: More than body requirements

Skin Integrity, Impaired

Ineffective Airway Clearance

Self-care Deficits

Risk of Aspiration

Communication, Impaired Verbal

______________________________________________________________________

3. Head and neck

a. Head mesocephal nodule lesions scar hematoma bruits sound

normal sinuses tenderness pain facies leonine deformities

pale _______________ _________________ ________________

Trigeminal (V) nerve function positive negative

Hair scaly dry oily fall bald ____________________

Temporal artery weak strong regular irregular absent

Total: ____

&

face


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b. Eye conjunctiva anemis exophtalmos enophtalmos ptosis glaucoma

sunken eyeball icterus strabismus ulcer deviation conjugee

nystagmus cataract retinopathy papilledema emmetropia

myopia hyperopia presbyopia astigmatism photophobia

foreign body eyeglasses contact lens excessive tearing

inflammation hemorrhage exudates edema entropion

ectropion lagophtalmos redness aphakia swelling ____________

Pupil P E R R L A mydriasis constricted isochors

Abduscence (VI) nerve function positive negative

c. Ear symmetrical lesions thickening exudates odor pain redness

tenderness deformities __________________ ___________________

d.Nose symmetric deformities lesions exudates obstruction pink moist

red inflammation purpuration ____________ __________________

Olfactory (I) nerve function positive negative

e.

Mouth caries dentures indurations scaly ulcer nodules cracks moistpink cyanosis redness inflammation _________ ____________

No. of teeth:____________

Hypoglossal (XII) nerve function positive negative

Glossopharyngeal (IX) + Vagus (X) nerve function positive negative

Facial (VII) + glossopharyngeal (IX) nerve function positive negative

f. Throat and neck

symmetrical swelling masses pain on movement bruits sound

Jugular vein(s) distention pain on swallowing ____________________

Shoulder resistance weak strong

Lymph nodes small soft tender movable enlarged

Trachea midline symmetrical deformities deviation

Carotid artery weak strong regular irregular absent

Nursing Diagnoses:

Deficient Fluid Volume

Infection, Risk for

Imbalanced Nutrition: More than body requirements

Hyperthermia

Swallowing, Impaired

Oral Mucous Membrane, Impaired


Acute/Chronic Pain


______________________________________________________________________


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4. Chest

a. Inspection accessory respiratory muscle use lesions symmetrical thorax

redness scar dry skin warm squama swelling

gynecomastia retraction Barrel chest _________ ________

Breast symmetrical smooth extreme vascularity retraction

bulging discharge bleeding scaly indurations masses

______________

b. Palpation

Apical pulse weak strong regular irregular absent

Tactile fremitus normal increased decreased

c. Percussion resonance hyper-resonance dullness tympani

Diaphragmatic excursion 3-5 cm < 3 cm >5 cm *(______cm)

d.

Auscultation bronchovesicular vesicular bronchial tubular/tracheal

crackles wheezing _________________ _______________

Nursing Diagnoses:


Activity Intolerance

Cardiac Output, Decreased


Ineffective Breathing Pattern

Impaired Gas Exchange

Self-care Deficit

Tissue Perfusion, Altered

Acute/Chronic Pain

______________________________________________________________________

5. Upper Extremities

a.

Inspection anemia jaundice hyper-pigmented vitiligo striae cyanosis

clubbing finger onycholysis ulcer sikatriks nevi deformities

spider nevi hirsutism ecchymosed paronychia ____________

b.

Palpation warm tenderness poor skin turgor ____________ ___________

Brachial pulses weak strong regular irregular absent

Radial pulses weak strong regular irregular absent

Ulnar pulses weak strong regular i rregular absent

Capillary refill normal slow

Senses Left Right

Light/Deep Touch

Sharp/dull

Warm/cold

Vibrations

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative


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c. Percussion:

Nursing Diagnoses:

Acute/Chronic Pain



Disturbed Body Image

Coping, Ineffective

Infection, Risk for

_____________________________________________________________________

6. Abdomen

a.

Inspection symmetrical bulges flat rounded ascites deformities

incision __________ ___________

Umbilicus midlined inverted

b.Auscultation

Bowel sounds

o

RLQ hyper hypo absent normalo LLQ hyper hypo absent normal

o LUQ hyper hypo absent normal

o RUQ hyper hypo absent normal

Bruits sound aorta renal arteries iliac no bruits sound

c. Percussion

o RLQ resonance hyper-resonance dullness tympani

o LLQ resonance hyper-resonance dullness tympani

o LUQ resonance hyper-resonance dullness tympani

o

RUQ resonance hyper-resonance dullness tympani

d. Palpation tenderness unusual lump ____________ _______________

Abdominal superficial reflexes positive negative

Nursing Diagnoses:

Acute/Chronic Pain


Constipation

Diarrhea_____________________________________________________________________

Senses Left Right

Biceps tendon reflex

Triceps tendon reflex

Brachioradial reflex

normal hypo hyper

normal hypo hyper

normal hypo hyper

normal hypo hyper

normal hypo hyper

normal hypo hyper


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7. Lower Extremities

a. Inspection anemia jaundice hyper-pigmented vitiligo cyanosis striae

excoriations Ulcer sikatriks nevi spider nevi hirsutism

ecchymosed alopecia ___________ ____________________

b. Palpation papule vesicle pustule squama crust nodule tumor

fissure sub-cutis emphysema dry skin moist warm

tenderness poor skin turgor _________________ _______________

Edema pitting grade: 0 (no pitting) +1(mild pitting)

+2 (moderate pitting) +3 (deep pitting) +4 (severe pitting)

Femoral Pulses weak strong regular irregular absent

Popliteal pulses weak strong regular irregular absent

Posterior Tibia pulses weak strong regular irregular absent

Dorsalis Pedis pulses weak strong regular irregular absent

c.

Percussion

Nursing Diagnoses:

Mobility, Impaired Physical



Acute or Chronic Pain

Infection, Risk for

Self-care Deficit


______________________________________________________________________

8. Genitalia

-Male bulges tenderness hernia scar secretion tumor

varicocele hydrocele inflammation odorous nodule

swelling redness dirty ___________ _______________

-Female inflammation ulcer secretion swelling nodule

cystocele rectocele bulges odorous tenderness

scar redness dirty ____________ _____________ _________

Senses Left Right

Light/Deep Touch

Sharp/dull

Warm/cold

Vibrations

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative

positive negative

Senses Left Right

Quadriceps reflex

Achilles tendon reflex

Babinski sign

normal hypo hyper

normal hypo hyper

normal abnormal

normal hypo hyper

normal hypo hyper

normal abnormal


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Nursing Diagnoses:

Infection, Risk for

Acute or Chronic Pain


_________________________________________________________________________________

C. Social Data

Social status single married widow divorced

Social activities organization(s) :_________________________________________________

not involved

Nursing Diagnoses:

Social Interaction, Impaired

Social Isolation

Loneliness, Risk for

Coping, Ineffective

_________________________________________________________________________________

D. Spiritual Data

Worship attendance always often sometimes rare never

Needs priests/friends to pray yes no

Nursing Diagnoses:

Spiritual Distress

Hopelessness

____________________________________________________________________________

E. Psychological Data

Expression sad frowning smiling comfort appearance _________

Emotion anxious afraid angry irritability relax _____________

Coping strategy independent need assistance

Nursing Diagnoses:

Anxiety

Hopelessness

Coping, Ineffective

_________________________________________________________________________________


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VII. Diagnostic Tests

No. Kinds of Test Normal Values Patients result Interpretation

Other Tests


12/12

IX. Data Analysis

S and O data Etiology Problem

X. Nursing Diagnosis According to Priority

1.

2.

3.

4.

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