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I. Introductio

II. Objectives

General Objectives

Special Objectives:

III. Developmental Task

Physical

Motor development

Language

Patients Profile

Name :

Address :

Age :

Gender :

Civil Status :

Religion :

Birth Date :

Attending Physician :

Date of Admission :

Diagnosis :

History of Past Illness

History of Present Illness


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IV. Physical Assessment

Physical assessment done:

Level of Consciousness:

Body Part Normal Finding Actual Finding Interpretation

A. Head

1. Skull

Inspection Proportional to the

size of the body,

round, with

prominence in the

frontal area interiorly

and the occipital are

posterior symmetrical

in all planes, gently

curved.

Palpation No area of

tenderness, lumps,

and has a smooth

skull contour.

2. Scalp

Inspection White, clean, free

from masses, lumps,

scars, lice, nits and

dandruff and lesions.

Palpation No area of tenderness

3. Hair

Inspection Black evenly

distributed and covers

the whole scalp, thin

and shiny.


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Palpation Coarse or fine. Hair

may feel thin, straight,

thick, or curly.

4. Face

Inspection Oblong or Oval or

round or square or

heart-shaped,

symmetrical, facial

expression that is

dependent on the

mood or true feelings,

smooth and no

voluntary muscle

movement.

5. Eyes

Inspection Parallel and evenly

distributed and placed

symmetrically, non-

protruding, with scant

amount of secretions,

both eyes bright and

clear.

6. Eyebrows

Inspection Black, symmetrical,

thick, evenly

distributed and

parallel to each other.

7. Eyelashes

Inspection Black evenly

distributed and turnedoutward.

8. Eyelids

Inspection Upper lid covers a

small portion of the

iris, cornea and the

sclera when the eyes


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are open. When the

eyes are closed the

lids meet completely,

symmetrical.

Palpation Non palpable, not

tender

9. Lower Palpebral

Conjunctiva

Inspection Salmon, pink, shiny,

moist

10. Sclera

Inspection White, clear with

some small,

superficial vessels

and without exudates,

lesions and foreign

bodies.

11. Cornea

Inspection Transparent, shiny,and smooth with no

presence of discharge

and irregularity.

12. Pupils

Inspection Round, equal and

reacts to light and

accommodation:

constrict when light is

pointed to the eyesand dilate when light

is removed.

13. Iris


size of the eyes,

round, black/brown


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and symmetrical.

Ears

Inspection Parallel, symmetrical,

proportional to the

size of the head,

bean-shaped, helix is

in line with the outer

canthus of the eye,

skin is the same color

as the surrounding

area and is clean.

Palpation Firm cartilage and the

patient should not

complain of pain or

tenderness during

palpation.

Ear Canal

Inspection Pinkish, clean with

scant amount of

cerumen and a few

cilia.

14. Nose

Inspection In the midline,symmetrical and

patent and is without

swelling, bleeding,

lesions and masses.

Internal Nares

Inspection Clean, pinkish with

few cilia.

Septum

Inspection

Straight in the midline

and without

perforation.


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15. Mouth

Lips

Inspection Pinkish, symmetrical

with lip margin, well

defined, smooth, and

moist. And show no

inflammation.

Gums

Pinkish, smooth,

moist no receding, no

swelling and no

discharge.

Teeth

Inspection Well-aligned, freefrom caries or filling,

no halitosis

Frenulum

Inspection Midline, straight and

thin.

Cheeks

Pinkish ,smooth and

moist. Free of lesions.

Tongue

Inspection Midline or medium,

red or pink, slightly

rough on top, smooth

along the lateral

margins moist, shiny

and freely movable.

Cheecks (buccal

mucosa )

Inspection Pinkish, smooth and

moist. Free of lesions.

Soft Palate

Inspection Pinkish, smooth, and


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moist. No lesion or

malformation.

Inspection Slightly pinkish, many

ridges. No lesion and

malformation.

Neck


size of the body and

head, symmetrical

and straight. Can

move the head

through a full range of

motion without

complaint ofdiscomfort .

Upper

Extremities

Inspection Clean no lesions,

digits/fingers equal in

number, symmetrical

no abnormalities.

Palpation No tenderness, ormasses; smooth and

temperature uniform.

Nails

Inspection Convex in curvature.

Normally have a pink

cast.

Palpation Smooth in texture;

prompt return of usualcolor upon release of

pressure.

Lower extremities

Inspection Lower extremities are

symmetrical and

equal in size, length.


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Hair distribution

variable. Feet clean

and no lesions.

Palpation Texture smooth,

temperature uniform.

V. Gordons Functional Health Pattern

A. Health perception and health management

B. Nutritional and metabolic pattern

C. Elimination pattern

D. Activity-Exercise pattern

E. Sleep-Rest pattern

F. Cognitive-Perceptual pattern

G. Self perception and Self concept pattern


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H. Role relationship pattern

I. Sexuality reproductive pattern

J. Coping stress tolerance pattern

K. Value belief pattern

VI. Anatomy and Physiology

VII. Pathophysiology

Disease:

PREDISPOSIN

G FACTOR:

PRECIPITATING

FACTOR:

Age :

Gender :


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VIII. Laboratory Result

Urinalysis

Actual Normal Significance

Color :

Transparency :

Pus Cells :

straw yellow to amber

transparent

absent

DxS/Sx

MANAGEMENT:


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Red Blood Cells :

Epithelial Cells :

absent

absent

Clinical Chemistry


Sodium :

Potassium :

135 148 mmo/L

3.5 5.3 mmo/L

Hematology


Hemoglobin :

Hematocrit :

Segmenters :

Lymphocyte :

F : 12 14 g/dLM : 14 16 g/dL

F : 0.37 0.47M : 0.40 0.57

60 70 %

30 40 %


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Platelet count : 130- 400 x 10

XI. Discharge Planning

Medication-

Exercise-

Treatment-

Health teaching-

Outpatient-

Diet-

Spiritual-

Assessment Guide

I. General Data

Name :

Birth Date:

Address :

Rm & Bed No. :

Religion:

Age:

Informant:

Date:


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II. Nursing History

A. Chief Complaint :

B. Past Health History :

C. Family History :

D. Usual pattern of Functioning

1. Physical activity

2. Food and Fluid Intake

a. Food dislikes:

b. Feeding problems:

3. Sleeping Pattern: takes

4. Elimination pattern:

a. Bowel :

b. Bladder:

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