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ANTHONY’S COLLEGE
Nursing Department
San Jose, Antique
I. VITAL INFORMATION
Name:
Age:
Address:
Civil Status:
Date and Time Admitted:
Chief Complaint:
Ward:
Bed No.:
Allergies:
Religious Affiliation:
Physician’s Initial:
Impression/Diagnosis:
4. LMP:
5. EDC:
6. Prenatal Check-up:
7. Description of Present Pregnancy:
8. Medications Taken During Pregnancy:
9: Discomforts on Present Pregnancy:
B. GYNECOLOGIC HISTORY
F. PATIENT’S EXPECTATIONS
Towards Hospitalization:
G. PATTERNS OF FUNCTIONING
a. Breathing Patterns
Respiratory Problems:
Usual Remedy:
Manner of Breathing:
b. Circulation
Usual Blood Pressure:
Any history of chest pain, palpitations, coldness of extremities, etc.:
c. Sleeping Patterns
Usual Bedtime:
No. of Pillows:
Bedtime Rituals:
Problems regarding sleep:
Usual Remedy:
d. Drinking Patterns
Total amount of fluid intake/day:
Kinds of fluid usually taken:
e. Eating Patterns
Food likes:
Food dislikes:
f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems/Difficulties:
Usual Remedy:
2. Urination
Frequency:
Problems:
Usual remedy:
g. Exercise
h. Personal Hygiene
1. Bath
Type
Frequency:
Time of Day:
2. Oral
Frequency of Brushing:
Care of Dentures:
3. Shaving
Frequency:
4. Use of Cosmetics
i. Recreation
j. Health Supervision
b. Occupation:
c. Religious Practices:
d. Persons Significant to the Patient:
e. Social Role:
f. Economic Status:
h. Lifestyle:
J. CLINICAL INSPECTION
1. Vital Signs
Date and Time Taken:
T=
PR =
RR =
BP =
2. Height:
3. Weight:
4. Physical Assessment
General Appearance:
a. Skin
b. Etc ….