Name: ________________________________________

Year/Section: __________________________________
Date of Submission: _____________________________
Clinical Instructor: ______________________________

Score: ___________________

PHYSICAL ASSESSMENT TOOL

1. PROFILE
Name: __________________________________________________
Address: ________________________________________________
Date of Admission: ___________________ Time: _______________
_______
Arrived via:
Wheelchair
Stretcher
Ambulatory
Admitting M.D. ______________________
Source Providing Information:
Patient
Other: ______________

II.

Age: ________ Sex: __________

Status: ____________________
Weight: ______ Height:
Temp: _______ Pulse: ________
RR: _________ BP: ___________

NURSING HISTORY

A. Chief Complain (Onset, Duration, Pt.s Perception):

_______________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
________
B. History of Present Illness (HPI) (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms,
previous treatment and results, social and vocational responsibilities, affected diagnosis)

I. Past Medical History

a. General State of Health
b. Childhood Illness
c. Adult Illness
d. Psychiatric Illness
e. Accidents and Injuries
f. Surgeries
g. Hospitalizations
D. Current Medical Status
a. Current Medications
b. Allergies
c. Tobacco (frequency, amount, duration)
d. Alcohol, drugs and related substance (frequency, amount, duration)
e. Diet
f. Screening Test
g. Immunizations
h. Exercise and Leisure Activities
i. Sleep Patterns
j. Environmental Hazards
k. Use of Safety Measures
E. Family History with Genogram

Heredo-familial disease
Diabetes
Heart Disease
Hypertension
Stroke
Cancer
Arthritis
Rheuma
Allergies
Asthma
Epilepsy
Mental Illness
Other (Please specify)

_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____

Acquired Diseases:
Hypercholestereloremia______
Kidney Disease
______
Tuberculosis
______
Alcoholism
______
Drug addiction
______
Hypertension
______
Hepatitis A
______
B
______
C
______
Other (Please Specify) ______
Diagram (with legend)

F.

Psychological History
a. Home Situation and Significant Others
b. Daily Life
c. Important Experiences
d. The Patients Outlook

III.

REVIEW OF SYSTEM

Weight: ______________

Height: ____________
Temp: ___________ PR: _____________ RR:
____________ BP: ____________
General Condition
Integumentary
HEENT
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Excretory
Endocrine
Musculoskeletal
Neurological
Reproductive

IV.

SUMMARY OF INTERACTION

NURSING ASSESSMENT
Name: ______________________________________________________________________________
Age ______________
Sex
_____________
Chief Complain:
________________________________________________________________________________________________________________________________________________
________________________________________
Impression/Diagnosis:
________________________________________________________________________________________________________________________________________________
__________________________________
Date of Admission _____________________________________________________________________
Inclusive Dates of Care
_____________________________________________________________
Diet
________________________________________________________________________________________________________________________________________________
__________________________________________________
Type of Operation (if any)
________________________________________________________________________________________________________________________________________________
_______________________________
Normal Pattern
Before Hospitalization
Initial
Clinical Appraisal
Day 1
Day 2
1. ACTIVITIES
REST
A. Activities

B. Rest

C. Sleeping
Pattern

2. NUTRITIONAL

METABOLIC
PATTERN
A. Typical Intake
(food, fluid)
B. Diet
C. Weight
D. Medications/Su
pplement
3. ELIMINATION
PATTERN
A. Urine
(frequency,
color,
transparency)

B. Bowel
(frequency,
color,
transparency)
4. EGO INTEGRITY
A. Perception of
Self
B. Coping
Mechanism

C. Support System

D. Mood/Affect
5. NEURO
SENSORY
A. Mental State

B. Conditions of 5
senses (sight,
hearing, smell,
taste, touch)
6. OXYGENATION
A. Vital Signs
Pulse Rate
Heart Rate
Blood Pressure
B. Lung Sounds
C. History of
Respiratory
Problems

7. PAIN COMFORT
A. Pain (location,
onset,
character,
intensity,
duration,
associated
aggravation)

B. Comfort
Measures /
Alleviation

C. Medications

8. HYGIENE AND
ACTIVITIES OF
DAILY LIVING

Sexuality
Reproductive
Pattern
A. Female
(Menarche,
Menstrual Cycle,
Civil Status,
Number of
Children)

B. Male
(Circumcision,
Civil Status,
Number of
Children)

LABORATORY AND DIAGNOSTIC PROCEDURE

DATE

NAME OF PROOCEDURE

RESULT

NORMAL VALUE

NURSING IMPLICATION

DRUG STUDY
Brand Name
Generic Name
Classification

Prescribed and
Recommended
Dosage,
Frequency, and
Route of
Administration

Mechanism of
Action

Indication

Contraindication

Adverse Reaction

Nursing
Responsibilities

DRUG STUDY
Brand Name
Generic Name
Classification

Prescribed and
Recommended
Dosage,
Frequency, and
Route of
Administration

Mechanism of
Action

Indication

Contraindication

Adverse Reaction

Nursing
Responsibilities

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

NURSING MANAGEMENT

SURGICAL MANAGEMENT

DISCHARGE PLAN
Patients Name _____________________________________________________________________
______________________________________________________
Condition Upon Discharge ____________________________________________________________
Request ( ) Discharge Against Medical Advice ( )
1. MEDICATIONS

Date of Discharge
Nature: Home per

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE OF NEXT VISIT

SUMMARY OF INTRAVENOUS FLUIDS

DATE AND TIME STARTED

INTRAVENOUS SOLUTION

PRESCRIBED RATE

HOURS TO RUN

DATE AND TIME

CONSUMED

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION