Professional Documents
Culture Documents
Objective (Exhibits)
Observed response to activity: Unable to tolerate ambulation; radial
pulse increase by 10-15 bpm from basal pulse
Specific activity: Walk (Assuming you let pt walked-IF NOT CONTRA)
GENERAL INFORMATION
Name: Last Name / First Name / Middle Initial
______
Age: _______
Birthdate: MM/DD/YY____________
Address: ______________________________________________
Admission: Date:_____ Time: _________
From: Home: _________________________________________
Hospital: ________________________________________
Others: Ambulance Paramedics pick-up from home
HEALTH HISTORY
Reason for this visit (chief complaint): Masaki tang dibdib ko or
Just plain chest pain, SOB, dizziness, etc.
History of Present Illness: Condition started 2 weeks PTA as
increasing body weakness, limiting performance of household chores,
swelling of ankles & feet late PM, & nocturnal dieresis 60cc X4. 5 days
PTA, felt on and off chest heaviness aggravated by activity, radiating
to left arm, relieved by rest & unrecalled medications. Consulted
family physician who referred her to this institution.
History of Past Surgeries/ Hospitalizations: No previous hospitalization
and surgery of Unremarkable medical/surgical history
Diagnoses/ Impressions: CAD, CKD, DM Type 2
Source of Information: Patient and daughter
Date: 03/30/11
ACTIVITY/ REST
Subjective (Reports)
Occupation: Government employee
Able to participate in usual activities/ hobbies: Yes but with support
or assistance
Leisure time/ diversional activities: Reading pocket books, watching
Mara Clara
Ambulatory: Yes with assistance or support (Y/N-describe)
Gait (describe): Normal / limp/ unsteady/ loss of balance/fear of falling
(Others: spastic, scissors, steppage, ataxic, parkinsonian)
Activity level (sedentary to very active): sedentary/moderately
active/vigorously active/extremely active
Daily exercise (type): brisk walking
Muscle mass/ tone/ strength (e.g normal, increased, decreased):
_______________________________________________________
_______________________________________________________
History of problems/ limitations imposed by condition (e.g. immobility,
cant transfer, weakness, breathlessness):
________________________________________________________
________________________________________________________
________________________________________________________
Feelings (e.g. exhaustion, restlessness, cant concentrate
dissatisfaction): ___________________________________________
________________________________________________________
Sleep: Hours 6 hours
Naps: 20 mins X2/day (10AM/3PM)
Insomnia:Y/N
Type: Initial / terminal / Intermittent
Rested on awakening: Y/N
Excessive grogginess: Y/N
Bedtime rituals: Glass of milk, scented candle bath
Relaxation techniques: yoga, spa, bubble bath
Sleeps on more than one pillow: Y/N # of pillows (due to DOB?)
Oxygen use (type): 4LPM/NC
When used: Continuous
Objective data
Medications/ herbals for/affecting sleep: Y/N- list the medications
________________________________________________________
______________________________________________________
Before Activity
HR 90
RR 20
BP 140/90
Immediately after
100
25
150/100
After 5 minutes
90
20
140/90
Page 1
Pulses: Carotid: 70
Describe: 4+
Temporal:__________
Describe:____________________________________________
Brachial: __________
Describe: ___________________________________________
Radial: ____________
Describe:____________________________________________
Ulnar: _____________
Describe: _____________________________________
Dorsalis pedis: ___________
If dorsalis pedis absent or abnormal,
post tibial_______________________________________
If post-tibial pulse absent or abnormal,
popliteal: ______________________________________
If popliteal pulse absent or abnormal,
femoral: ______________________________________
Cardiac (palpation): thrill Y/N
heaves: Y/N
Heart sounds (auscultation):
Rate:96
Rhythm: Irregular Quality: +2
Friction rub: Y/N
Murmur (describe location/ sounds): Y/N
Vascular bruit (location): Y/N
Jugular vein distention: Yes
Breath sounds: location: Rales, bibasal (Crackles, wheezes, rhonchi)
Description: Coarse / fine
Extremities:
temperature: warm/cold color: pale capillary refill: 1-2 secs
Homans sign: Y/N
varicosities (location): Y/N
Nail abnormalities: :Leukonychia, splinter hemorrhage, clubbing
edema(location/ severity +1 to +4): +3, lower extremities, bilateral
Distribution/ quality of hair: Equal (velus & terminal hairs)
Skin lesions: type:Macule, papule, vesicle, bullae, keloid, scar
location: describe the location + size
color: Reddish, necrotic, purplish
Nursing Diagnosis:
________________________________________________________
________________________________________________________
_____________________________________________________
EGO INTEGRITY
Subjective (Reports)
Marital status: Singe, married, separated, widow, complicated?
Expression of concerns (e.g. financial, lifestyle or role changes):
Walang mag-aalaga sa mga anak ko / None as of the moment
Stress factors: Workload, supervisor, noise
Usual ways of handling stress: watching TV, spa, yoga
Ways of expressing feelings:
Anger: Break glass, shout at co-workers, be quiet
Anxiety: nail-biting
Fear: go to church, magtago sa ilalim ng bed
Grief: cry, pray
Others (hopelessness, helplessness, powerlessness): pray
Cultural factors/ ethnic ties: Canao
Ethnic group: Kankanaey
Religious affiliation: Roman Catholic
Active/ Practicing: Y/N
Practices (prayer/meditation, etc.): Novena, rosary
Religious/ Spiritual concerns: Anti-RH bill, no to abortion
Desires clergy visit: Y/N
Expression of sense of connectedness/ harmony with self and
others: Prayer meetings, social gatherings, bingo social
Medications/ Herbals: List of medications affecting ego-integrity
Objective (Exhibits)
Emotional status (check those that apply):
Calm: ______ Anxious:_________ Angry: _______________
Withdrawn: __________ Fearful: ______Irritable: __________
Restive: ________ Euphoric: ___________
Page 2
Objective (Exhibits)
General appearance: Manner of dressing: clean, appropriate to age
and climate, fit to body
6
5
4
3
2
1
5
4
3
2
1
15
Page 3
Instructions
Date
"Tell me the date?" Ask for
Orientation omitted items
Place
"Where are you?" Ask for
Orientation omitted items.
Register 3
Objects
Serial
Sevens
Recall 3
Objects
Naming
Repeating
a Phrase
Writing
Drawing
Scoring
Scoring
30
RESPIRATION
Subjective (Reports)
Dyspnea related to: Orthopnea, exertion
Precipitating factors: Activity Relieving factors: Rest
Cough (describe): productive, non-pro, able or unable to expectorate
sputum (describe character): rusty, approx 10cc per expectoration
Requires suctioning Y/N
History of (year): bronchitis:
asthma:
emphysema: ____tuberculosis: __recurrent pneumonia: ______
exposure to noxious fumes/ allergens: ___
Infectious agents/ diseases/ poisons/ pesticides:
_______________________________________________________
Smoker: Yes: ___ No: ___
Type (e.g. menthol) ________ sticks/packs per day: ________
No. of Yrs: ____________
Use of respiratory aids: oxygen, nebulizers, ventilators, etc
Oxygen (type/ frequency): 4LPM / NC, FM, Non-rebreather, ect
Medications/ herbals: ______________________________________
_______________________________________________________
_______________________________________________________
Objective (Exhibits)
Respirations
Spontaneous: Rate: 96
Depth: deep
Assisted: Y/N Parameters: _______________________________
_____________________________________________________
O2 inhalation: Y/N Type: NC, FN, Non-rebreather
Flow Rate: ____________________________________________
Chest excursion (equal/ unequal): symmterical
Fremitus: buzzing at ulnar aspect of hand, more pronounced at..
Use of accessory muscles: Y/NSCM, Scalene, trapezius
Nasal flaring: Y/N
Breath sounds: wheezes, rales, crackes, stridor
Egophony:muffled: Y/N
clear: Y/N
Skin/ mucous membrane color: Pinkish
clubbing of fingers: Y/N
Sputum characteristics: Yellowish-copious
Pulse oximetry: 94% at 4LPM/NC
Page 4
(Front)
(Back)
time
Dilatn
Effacet
BOW
Cond.
station
discharges
Done By
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Page 5
Yr
Method
of Del.
Place of
del./attended
by
Birth
wt
Condn
Condn of
baby
1986
NSVD
Home/
midwife
2.6
kg
Hospital/
physician
1.8
kg
Tolera
ted
labor
and
deliver
y
Arrest
in
labor
thus
CS
Adapte
d to
extraute
rine
environ
ment
Adapte
d to
extraute
rine
environ
ment
1990
LSCS
Prenatal History
d1) General physical and emotional state of the mother during
pregnancy: observed expected physiologic changes of
pregnancy , planned and accepted pregnancy, ______
__________________________________________________
d2) Prenatal check up/consultations:
1st trimester (frequency): once_________________________
Diagnostic & result: VDRL negative resul, CBC- Hgb =8
g/dL, Blood type= B(+) Rh (-)_____________
2nd trimester:once _________________________________
Diagnostic & result: ultrasonography=singleton, male,..____
3rd trimester: no prenatal_____________________________
Diagnostic & result: none__________________________
d3) Pregnancy complications & discomforts during present
pregnancy(if any)- nausea and vomiting: Y/N_______________
loss of appetite: Y/N ____ edema: Y/N _____ UTI : Y/N _____
co morbid illness: hypertension,...______ Vagl bleeding: Y/N
abnormal weight change: Y/N ______ HPN: Y/N _______
d4) Was pregnancy planned: Yes: ______ No: ______
when was quickening felt: 5 months gestation_____________
attitude of father: accepted pregnancy, supportive___________
place where mother plans to give birth: birthing facility/home
_________________________________________________
Gynecologic History (Date):
a.) Surgery affecting the: breast: Y/N _____ Mastectomy: Y/N ____
hysterectomy: Y/N ___ Hysterectomy: Y/N ___ TAHBSO : Y/N
b.) Ectopic pregnancy: Y/N _______
c.) Reproductive tract diseases: PID: Y/N ______
Polycystic ovarian disease: Y/N ______ H-mole : Y/N _____
Others: specify: STI__________________________________
d.)Breast:(symmetrical):symmetrical/assymetrical ______
size and shape ______ retractions/ dimpling: Y/N ______
nipple discharge: Y/N _______ redness of the skin: Y/N
_____ visible superficial veins: Y/N _____ lumps or masses
on both breasts: Y/N _______ axillary lymph node mass:
Y/N _____ tenderness: Y/N __________
d.) Abdomen: (minimal) gravidarum striae: Y/N _______
(protruded) umbilicus Y/N ______ fundic height 20 cm :
__________ tenderness: Y/N _______ (occasional/mild)
uterine contractions: (frequency /intensity/interval/duration)
________ fetal movement 10-12 ./ hour______________
bowel sounds:
no. per minute
25
*Leopolds Maneuver:findings: describe:
LM I: round firm parts ______________________________
_______________________________________________
_______________________________________________
LM II: left: smooth flat, right: nodular prominences,
longitudinal lie, FHT site at LUQ______________________
_______________________________________________
LM III: irregular , soft parts__________________________
_______________________________________________
_______________________________________________
LM IV: engaged/ ballotable,/ completely flexed, partially
flexed, extended, military attitude _________________________
_______________________________________________
_______________________________________________
e.) Genitourinary tract:
(Darkly pigmented) inguinal region: Y/N _________________
vaginal secretions (watery or bloody): Y/N _______________
presence of haemorrhoids: Y/N ______________________
f.) Extremities: symmetrical length: Y/N _____________________
size upper and lower extremities: ___________________
edema: Y/N _ varicosity: Y/N __ limitation of ROM Y/N ____
swelling of joints: Y/N ______ peripheral pulses: _______
tenderness: Y/N ______ claudication: Y/N ___________
g.) Integumentary: gravidarum striae-: Y/N ____________________
specify location: abdomen______ lesions: ____ rashes: ___
hematoma/petechiae: Y/N _____ chloasma: Y/N _______
Post Partum
h.) Abdominal status:
location and size of the uterus: 1 cm below umbilicus,_______
condition of the uterus: soft boggy_______________________
i.)GUT status: presence of vaginal discharge: Y/N _________
amount: 4 fully soaked pads in 2 hours___ color: bright red___
condition of the perineum ( particularly if episiotomy is done):
eryhtematous, ecchymosed, approximately 5 cm on the RML
area ______________________________________________
functioning of the bladder (time and amount of first urine, time
of first BM postpartum) urine 250 mL 2 hours after delivery,
bowel movement after 8 hours of delivery _______________
_________________________________________________
j.) Emotional/ Psychological Status
postpartum blues: Y/N ________ depression: Y/N __________
heightened emotional reactions/labile moods: Y/N _________
_________________________________________________
Menopause: Y/N _____ onset: 55____________
Hysterectomy/ Oophorectomy: Y/N _________________________
Problem with: Vaginal lubrication: Y/N _____ hot flushes: Y/N _____
Vaginal discharge: Y/N ______ others: ____________________
Hormonal therapies: Y/N ________________________________
Osteoporosis medications: Y/N ____________________________
Practices BSE: Y/N ____ Last mammogram: date _______________
Last Pap smear: date_________ Results: ______________________
Objective (Exhibits)
Genitalia (warts/ lesions): none_______
STI test results: _________________________________________
vaginal bleeding/ discharge: ________
Management: Meds: prescribed:___________________________
_______________________________________________________
Nursing Diagnosis: ______________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Objective (Exhibits)
Genitalia: Penis (circumcised): Y/N warts/ lesions: Y/N
bleeding/ discharge: Y/N Testicles (e.g. lumps): Y/N
Breast examination: Y/N
STI test results: __________________________________________
_______________________________________________________
Nursing Diagnosis: _______________________________________
_______________________________________________________
_______________________________________________________
Page 6
SOCIAL INTERACTIONS
Put a check mark
Subjective (Reports)
Relationship status:
Single: _____ Married: _______
Separated/ Annulled/ Divorced: ________ Widowed: ______
Living with (Specify): ____________________________________
Yrs of Relationship:__________
Perception of relationship: happy living alone
Concerns/ stresses: no one to talk to when sad
Role within family structure: breadwinner
Number/ Age of children: __________________
Perception of relationship with family members: happy being the lone
provider to the needs of children
Extended family: Y/N
other support persons: __________________________________
Ethnic/ Cultural affiliations: _______________________________
Strength of ethnic identity: _______________________________
Feelings of (describe):
Mistrust: Y/N
Rejection: Y/N
Unhappiness: Y/N, sometimes, seldom, rare
Loneliness/ Isolation: Y/N
Problems related to illness/ condition: Unable to work
Problems with communication (e.g. speech, another language, brain
injury): ______________________________________________
Use of speech/ communication (list)_______________________
____________________________________________________
Is interpreter needed:Yes ______ No ______
Primary language: _________________________
Objective (Exhibits)
Communication/ speech: Clear: ______ Slurred: _______
Unintelligible: _____ Aphasic: ______
Put a check mark
Unusual speech pattern/ impairment: _____
Laryngectomy present: _____
Family interaction (behavioural pattern): open communication to
children, free to express their emotions