Professional Documents
Culture Documents
COLLEGE OF NURSING
ASSESSMENT FORM
GENERAL INFORMATION
Patients Name:
Patient X
Age : 32yrs.old
Sex:
___Female
Address: __Zone 10, Zayas, Cagayan de Oro City
Status:
_married
_____
Religion:Roman Catholic__
Educational Attainment: _ High School graduate
Occupation:
______housewife___________________________
Nationality: __Filipino_________ _______________
Income:____________N/A__
_______________________
Name of Spouse/Guardian: __XXX___________________
Contact
Number:
___N/A____________________________
Date of Admission (MM/DD/YY): ___September 4,2012____________
Time of Admission :
____10: 00 AM__________
Baseline Vital signs: BP: _______80 / 50mmHg________ _
T: _36.3C
_ PR: ___104 bpm___
RR: _ 42 cpm _
Weight upon admission (in Kg): _______N/A________________
Height
(in
ft
&
in):
______N/A________________
CHIEF COMPLAINTS
Vaginal Bleeding
HISTORY OF PRESENT ILLNESS
Four Days Prior to Admission, Patient noted vaginal bleeding but she was not alarmed.
So, she doesnlt seek medical assistance. The day Prior to admission,The patient notice continous flow
of blood with fetus and she was immediately brought to Northern Mindanao Medical Center .
DATE OF ADMISSION
September 4,2012
NAME OF INSTITUTION
Northern Mindanao Medical Center
HOSPITALIZATION HISTORY
ALLERGIES:
Yes
No
Food: _____________________
_____________________
DIAGNOSIS/INDICATION
Incomplete Abortion
No
INDICATION
For blood Loss
REACTION
None
INDICATIONS
Date
ordered
(mm/dd/
yy)
9/4/12
9/4/12
9/5/12
9/5/12
IV fluids/blood
Date discontinued
(mm/dd/yy)
No
_____
Pinkish
_____
Midline
9/4/12
No ___/_
No ___/_
Obesity
_____
Teeth
__/___
Complete
_____
Pallor
__/___
Caries
_____
Cyanosis
_____
teeth___/__
Lesions
_____
Dentures
_____
Dryness/cracks _____
Gums
Pinkish
_____
Tenderness _____
Pharynx:
Uvula
Midline
___/__
R/L deviation _____
Pallor
__/___
Cyanosis _____
Atrophy
_____
Fasciculation _____
Missing
Pallor
Mucosa
Pinkish ___/__
Pallor
Reddish _____
__/___
Bleeding
_____
Tonsils
Not inflamed __/___
_____
R/L Deviation _____
R/L Exudates _____
Neck:
Trachea
Others: N/A
Midline
__/___
R/L deviation __/___
Neck enlargement ____
_Lymphadenopathy
_____ Tenderness _____
ROM
_____
Cervical Lymph Nodes _____
_____
Skin:
General Color
Texture
Pinkish
_____
Smooth
__/___
Dry
__/___
Cyanotic
_____
Rough
_____
Moist/Clammy
_____
Pallor
___/__
Others:
Flushed
_____
_______________
Jaundiced
_____
Mottled
_____
Dusky
_____
Thyroids
Non-palpable __/___
Enlarged
_____
Normal
Neck
Temperature
Warm
Cool
Others:
________________
rigidity
Moisture
__/___
_____
Wounds/drains/dressings:
_____N/A______________________________________________________________________________
Intravenous fluids: PNSS 1L@20gtts/min at Left arm, D5W+NaHCO3 150 meq.(terminate when
consumed with slight discomfort), Dopamine drip 54 cc/hr-discountinued
B. ELIMINATION PATTERN
Usual bowel pattern (Describe character of stool, frequency, discomforts)
Brown Semi-solid stool every other day (1-2 times)
Date of Last BM (mm/dd/yy): _
8/31/2012________________________
Melena _____
Hematochezia _____
Are there any problems with hemorrhoids/incontinence?
Yes __/___
No _____
Use of anything to manage bowels (e.g. laxatives, enema, suppositories, home remedies, antidiarrheals)
__________________________________________________________N/A__________________________________________
______________
Abdomen
General
Configuration
Percussion
Palpation N/A
Superficial Veins _____ Symmetrical
__/___ Tympanitic
__/___ Muscle
guarding
_____
Striae
_____ Asymmetrical _____ Hypertympanitic _____ Direct
tenderness
_____
Scars/Lesions ___/__ Flat
_____
Fluid wave
_____ Rebound
tenderness ____
Globular
_____
Shifting dullness _____ Bladder
distention
_____
Protuberant
_____
Dullness at:
Organomegaly:
Scaphoid
_____
Liver _____ Spleen ____
Masses at:
_____________________
Usual urinary pattern (Describe frequency, character, amount, problem in control, etc.)
____________Urinates for about 3 4 times a day, in a minimal amount, yellowish in
color____________________________________
Dysuria
_____
Hematuria _____
Nocturia _____
Retention _____
Flank pain _____
Polyuria
_____ Oliguria _____
Anuria
_____
Dyspnea
Palpitation
Paroxysmal
_____
Precordial area
Heart Sounds
Flat
_____
Distinct
_____
Bulging
_____
Regular
___/__
Tenderness _____
Faint
_____
Heave
_____
Irregular
_____
Thrill
_____
Others:
Apical rate and rhythm: S3 _____
S4 _____
________86 bpm_____________
Preicardial rub _____
Capillary Refill __2 sec________________________
Presence
of
Pacemaker/A-V
____none_____________________________
Respiratory Status:
Peripheral pulses
Symmetrical
Regular
Faint
_____
Strong
_____
Bounding
_____
Shunt/Hemodynamic
on
exertion
nocturnal
__/___
_____
monitoring
Breathing Pattern
Shape of chest
Regular
__/___ Irregular
_____
Eupnea
_____ Hyperpnea _____
Tachypnea _____
Bradypnea _____
Dyspnea __/___
Rest
_____
Exertion
_____
Use of accessory muscles _____
ICS retractions/bulging
_____
Pain on respiration
_____
Vocal/Tactile Fremitus
Percussion
Symmetrical __/___
Resonant ___/__
Decreased/increased at:
Dullness at:
____________________
______________
Hyperresonant at:
______________
O2
supplement/ventilatory
assistance
_______
N/A
______________
__________________________
Respiratory Tubes (e.g. ET, trach, chest tube/describe secretions and/or drainage)
_____________________none___________________________________________________
Limitation
assistance
regularity)
___/__
_____
Gait
_____
Lordosis
Scoliosis _____
Coordinated __/___
Smooth
Staggering _____
_____
Shuffling
Uncoordinated _____
Drowsy _____
Orientation
Emotional State
Oriented __/___
Calm ___/__ Worrried/Anxious _____ Restless
_____
Disoriented to:
Dizziness _____ Numbness
_____
Tingling Sensation _____
Time/Person/Place _____
Others: ________
Head:
Normocephalic __/__
Others: _______
Assymetrical _____
Facial Movements
Symmetrical ___/__
Assymetrical:
lag at R _____L _____
Hair
Fine
Coarse _____
Dry
_____
Alopecia _____
__/___
_____
Scalp
Clean
__/___
Dandruff _____
Lice
_____
Wounds/scars/lesions (specify)
________________________
Eyes:
Lids
Periorbital region
N/A
Conjunctiva
Cornea
and
lens
Symmetrical
___/__
Opacity:
R/L edema/swelling _____
_____ L _____
R/L ptosis
_____
Lesions _______
Lesions
_____
Visual Acuity
Edema
_____
Pink
_____
Sunken
_____
Pale
__/___
Lesions
_____
Discoloration _____
Discharges _____
Peripheral vision
Reaction to accommodation
External canal
Tympanic membrane
Discharge:
Intact
(N/A)
___/___
Tenderness _____
Symmetrical _____
Lesions
_____
Serous
_____
Purulent
______
R/L
deafness
_____
Gross abnormalities:
_________________
Mucoid
______
Cerumen:
Impacted
_____
Not impacted __/___
Nose
Alar flaring _____
Septum
Patency
Midline __/___
Deviated _____
Perforated _____
Mucosa
Discharge
Pinkish __/___
Serous _____
Pale _____
Mucoid _____
Reddish ______
Purulent ____
N/A
_____
Bloody ______
Masses/lesions(describe):
____________________
Gross smell
Sinuses N/A
Normal/Symmetrical __/___
Tenderness _____
R olfactory deficiency _____
Maxillary _____
L olfactory deficiency _____
Frontal _____
Cognition
Primary language __Visayan___________________________________
Speech
difficulties
________none_________
Are there any learning difficulties?
Yes ______
No ___/__
Are there any change in memory lately?
Yes _____
No ___/__
Pain
No problem _____/_____ Problem __________
Location
__
Type
__
___
Intensity
_
___ _ ___ __
Onset _
___
Duration
_
__
E. SLEEP REST PATTERN
Usual sleep/rest pattern
__5-6 hours of sleep._______________________________
Adequate:
Yes _____
No _____
Factors affecting sleep/rest
___Surroundings
(noise)_________________________________________________
Methods to promote sleep
___none___
______________________________________________________
F. SELF PERCEPTION AND SELF CONCEPT PATTERN
How
do
you
describe
yourself?
_______________________________________________________________________
Are there any ways the patient feel differently about his/herself since he/she has been
ill/hospitalized? ______________
_______________________________________________________________________________________________
_
Description of nonverbal behaviors: __Patient is weak and
tired.__________________________________________________
G. SEXUALITY REPRODUCTIVE PATTERNS
Are there any changes/problems with sexual relations? __none________________
Female
10
Menstrual pattern
_Normal____________
Date of LMP _May 8,2012_________
Pregnancy history
___G5P4__________________________________________________
Use of birth control measure: Yes __/___
Type:______Pills____________________
No _____
N/A
Monthly self-breast exam:
Yes _____
No _____
External Genitalia
Urethra
Vaginal Discharge
Labia:
Pinkish
_____
Purulent _____
Symmetrical __/___
Red/inflamed _____
Bloody __/___
Asymmetrical _____
Foul smelling _____
Edema
_____
Others:
Lesion
_____
Swelling _____
Lumps/nodules _____
Breast
Equal___/___
Unequal
Tenderness________________
Surface:
Smooth __/__
Retraction _____
Lesions _____
Masses at:
____________________
Others
____________________
_____________
Dimpling _____
Edema _____
RR: 28 cpm
Generalized weakness & Pale
Vaginal Bleeding
pale
Folley Bag Catheter
Attached to Urobag
11
wepalepapale
12