RLE Standard format

College of Nursing and Health Sciences

 Rle standard format
Patient Assessment

July 2010 CJVALEZA, RN, MAN 2

I. Patient Profile
NAME: EDUCATIONAL ATTAINMENT:
AGE: OCCUPATION:
GENDER: RELIGION:
STATUS: DATE AND TIME ADMITTED:
ADDRESS:

CHIEF COMPLAINTS:
ATTENDING PHYSICIAN:
DIAGNOSIS/IMPRESSION:

July 2010 CJVALEZA, RN, MAN 3

II. Health History
A. Present Illness
B. Past Health History
C. Family History
D. Birth and Obstetrical History
E. Feeding History (may also be written in food and
fluid intake)
F. Growth and Development History

July 2010 CJVALEZA, RN, MAN 4

A. Present Illness
Chief complaints.
Chronological Narrative account of the problem for
which the patient is seeking care. Describe the onset
of the problem. How and when did it start? What was
the setting or what was the patient doing at the time
of onset? What were its manifestations any
treatments? Describe physical symptoms in terms of
Location, Quality, quantity or severity, Timing (onset,
duration and frequency), the setting at which they
occur, factors that aggravated or relieved the
symptoms and associated manifestations. What
treatment taken at home? How did the patient
respond?
July 2010 CJVALEZA, RN, MAN 5
B. Past Health History
General state of health (as the patient perceives it)
Childhood illnesses experienced: measles, mumps, and
chicken pox, rheumatic fever, polio
Immunizations received: like DPT, measles, mumps, BCG
etc.
Adult illness. Type, how treated, recovered or not.
Operations, Injuries, Allergies.
Current medications taken: including home remedies,
non-prescription drugs, vitamin/mineral supplements
and medicines borrowed from family or friends. Asks
about frequency and dosage.

July 2010 CJVALEZA, RN, MAN 6

C. Family history

Illnesses experienced by other members of the

family.
Age and health or age and cause of death.
Occurrence within the family of any of the following
conditions: diabetes, tuberculosis, arthritis,
anemia, mental illness, heart disease, cancer.
Alcoholism, drug addiction, and symptoms like
those of the patient.

July 2010 CJVALEZA, RN, MAN 7

D. Birth and Obstetrical History

Menarche, GP, FPAL, EDC, AOG, previous use of

contraceptives
Prenatal. Maternal health before or during pregnancy.
Illnesses experienced by mother during pregnancy,
complications, drugs taken, duration of pregnancy.
Natal. Nature of labor and delivery. Birth order. Birth
weight. Complications during birth. Anthropometric
data, Ballard scoring,
Neonatal. Onset of respirations, estimation of
gestational age. Specific problem with feeding,
respiratory distress, cyanosis, jaundice, anemia,
congenital anomalies, infection.
July 2010 CJVALEZA, RN, MAN 8
E. Feeding History
Infancy.
1. Breastfeeding—frequency and duration of feedings,
use of complimentary or supplementary artificial
feedings, difficulties encountered, timing and
methods of weaning.
2. Artificial feeding—type of formula, concentration,
amount and frequency of feeds, feeding difficulties,
timing and method of weaning. Vitamin supplements
given.
3. Supplementary feeding—types and amount of food
given, when (age) introduced, infant’s response.

July 2010 CJVALEZA, RN, MAN 9

F. Growth and Development History
(FOR PEDIA)
Physical growth. Height. Weight at birth, ages 1, 2
5, and 10 years. History of rapid or slow gains or
losses in weight. Tooth eruption and loss pattern.
Developmental milestones—like ages at which
patient held up his head in prone position, rolled
form front to back, sat with support/alone,
walked, said first word, combination of words,
and sentences, tied own shoes, dressed without
help.

July 2010 CJVALEZA, RN, MAN 10

F. Growth and Development History
Social development:
a. Sleep patterns- amount and patterns during day and
at night, bedtime routines, type of bed and its
location, nightmares, terrors and somnambulating.
b. Toilet training (age, methods used, difficulties
encountered, terms used for defecation and
urination).
c. Speech - hesitations, stuttering, baby talk lisping,
estimated number of vocabulary.
d. Habits- head banging, thumb sucking, nail biting,
pica, ritualistic behavior, tantrums, aggression,
withdrawal.

July 2010 CJVALEZA, RN, MAN 11

F. Growth and Development History
Schooling – age entered school, achievement. Other
informations.
Personality – degree of independence, relationship
with parents/siblings, activities, and interests,
special friends, major assets and skills

(FOR ADULT)
Refer to Psychosocial Theory by Erikson that tells
about the different developmental tasks
according to stages of life.

July 2010 CJVALEZA, RN, MAN 12

 III. PATTERNS OF
FUNCTIONING AND CLINICAL
EXAMINATION GUIDE
(PHYSICAL ASSESSMENT)

July 2010 CJVALEZA, RN, MAN 13

 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
1. RESPIRATORY
a.  Hx of cough  productive Inspection: Results of chest X-
not productive  presence of cough  none ray
b.  Hx of asthma  not productive Results of sputum
 Hx of Bronchitis  productive examination
 Hx of emphysema Color:  greenish  bloody
Medications being
c.  Hx of dyspnea:  exertion  yellowish  pinkish
 during rest  others:____________ taken
d. Hx of PTB or cough more  Cough interferes with rest.
than Colds  Sneezing
2 weeks  nasal discharges
 relief measures done:  with tracheostomy
 respiratory aids use:
(Specify)______________ (specify)____________
 with CTT

July 2010 CJVALEZA, RN, MAN 14

 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING

e. None smoker Respiratory rate & rhythm & Results of chest X-
 smoker : pattern
ray
amount consumed Per day; RR: ____cpm
 normal/breath effortless Results of sputum
____packs ____sticks
 Abnormal: examination
How long: ____years
use of accessory muscles Medications being
f.  Hx of surgery related to lung rapid swallow breathing
problem : _____________ taken
(tachypnea)
g.  difficulty of breathing during  rapid deep breathing-hyperpnea,
sleep hyperventilation)
 Use of more than one pillow  slow breathing (bradypnea)
to  cheyne stokes breathing
sleep  obstructive breathing
asymmetrical lung expansion
h. exposure to environmental
 symmetrical lung expansion
inhalants (chemicals, Contour of chest
fumes) Palpation:
Percussion:
Auscultation of Lung sound
 normal breath sound/clear
 presence of adventitious breath
July 2010 CJVALEZA, RN, MAN 15
sound
 PATTERNS OF FUNCTIONING OTHER SOURCES
2.CIRCULATORY ECG results
History of : Blood chemistry
 HPN ;dizziness; heart problems:(specify)_______ Hematology
fainting spells , palpitations , heart defect, Hx of murmur Medications taken
 Hx of heart surgery
chest pains
location
 rating scale 1-10: ____
 radiating  not radiating
 Duration: _____mins.
associated symptoms: nausea, vomiting,  sweating
 relief measures done:___________________
Causes of attacks: ____________
 irregular heartbeat
 tachycardia
 bradycardia
Swelling(where):______________
discoloration(where):___________
edema experienced:
associated with what: _____________
July 2010 CJVALEZA, RN, MAN 16
CJVALEZA, RN, MAN July 2010 16
 CLINICAL EXAMINATION (CIRCULATORY)
BP: ___mmHg HR:___bpm PR:__bpm  complaints of headache (severity,
 Normal HR location): __________________
 tachycardia  associated symptoms of headache
 bradycardia (specify):_____________
 regular rhythm  irregular chest pains (severity,
 Normal pulse quality):__________________
 weak/small pulses easy fatigability,
 large/bounding pulses  palpitations
 bigeminal pulses  tightness of chest
 presence of swelling: where:_______ Capillary refill: ______secs.
varicosities of extremety/ies Color of nail beds:
 discolored parts: where:_________  cyanotic  pale
 Cyanosis  pallor Color of mucus membrane: ____________
cold extremities  warm extremities  heart murmurs
 edema : where:_____________  high pitch  medium  low
pitting  non-pitting Quality:  blowing  rumbling
circumference of edematous  harsh  musical
Extremities: _____cm. Nails:  pale nail bed
Redness in pressure areas: where: ___   pink nail bed
 clubbing on nails
July 2010 CJVALEZA, RN, MAN 17
CJVALEZA, RN, MAN July 2010 17
 PATTERNS OF FUNCTIONING OTHER SOURCES
3. FOOD AND FLUID INTAKE
Diet prescribed, fluids
Usual foods taken, meal pattern, How? prescribed, oral, parenteral,
Many meals does he take each day? Results of GI tract x-rays, liver
function tests, blood sugar level.
Time/
Food allergies
Food preferences and dislikes
No. of glasses of water taken each day.
Other beverages taken,
Does he take alcohol? Type? Average?
Amount consumed/session, frequency,
for how long has he been drinking?
Pedia patients: include feeding hx.

July 2010 CJVALEZA, RN, MAN 18

CJVALEZA, RN, MAN July 2010 18
 CLINICAL EXAMINATION
General state of health, body Texture: 
rough/thick nausea
builds nutritional state. 
smooth/soft vomiting (Amount): _______

Height: ____ft. Weight: Temp. & moisture of skin: frequency: _______
___kgs. Nutritional status of : 
warm 
cold 
hot 
loss of appetite
Skin: wet
 oily 
 dry swallowing difficult

poor skin turgor. Scalp/hair: abdominal pain(scale 1-10):
mildly dehydrated.
 
dandruff ____

moderately dehydrated. Brittle hair
 
dysphagia

severely dehydrated. scaly dry
 Actual foods taken(specify

evenly distributed fine hair Hydration of mucus quality/quantity):
Edema: pitting
 non-pitting membranes: 
dry 
moist _______________________
Eczema(scaling of the skin) Mouth:
 lips: Rate of IVF:______
Dry skin
 
dentures 
dry 
on Parenteral feeding
color of skin: 
dental carries moist
 
With NGT
dark skin 
white skin 
cracked

July 2010 CJVALEZA, RN, MAN 19
CJVALEZA, RN, MAN July 2010 19
 PATTERNS OF FUNCTIONING OTHER SOURCES
4. ELIMINATION Constipation (Cause): _______
Results of UGI series,
How many times does patient relief done: __________ barium enema, etc.
void/day?(specify): __________  diarrhea (cause): _________ Stool exam result.
Urinalysis result.
color: relief done :_________ Kidney function tests.
 straw to amber BM per day(specify): ____
 orange
Usual time: morning
 brownish
 reddish afternoon
smoky-colored urine evening
Amount: (specify): ____ Char. Of stool:  soft  hard
History of : Color:  brownish  black tarry
indigestion  dysuria  others: ______
nausea  dribbling  taking aids for elimination
vomiting specify: ________

July 2010 CJVALEZA, RN, MAN 20
CJVALEZA, RN, MAN July 2010 20
 CLINICAL EXAMINATION
Date of last BM: ____ Urine color:
Char. Of stool: 
soft 
hard 
straw to amber 
orange
Color: 
brownish 
black tarry 
brownish 
reddish

others: ______________ smoky-colored urine


melena 
perspiration: 
profuse 
not

constipation(duration):____days 
Passage of flatus
remedy:________________ 
abdominal distention

with colostomy 
abdominal tenderness

diarrhea: frequency: _________ 
hernia
Urinary frequency : Sounds in the abdomen: _______
Amount: (specify): ____________________ 
hematemesis(amount) :_____

urgency frequency: _______ 

dysuria 
abnormalities of anus noted

incontinence specify: ________

polyuria
F
oley in place
July 2010 CJVALEZA, RN, MAN 21
CJVALEZA, RN, MAN July 2010 21
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
5. REGULATORY
MECHANISMS Temp.: ____°C (Oral, rectal.
Fever before?, associated Axilla) Results of blood
with? Any chills? Relief Skin:  dry skin  moist examination
measures?  pale  cyanotic indicative of
Menarche, interval, no. of  hot to touch  infection process.
days. LMP? cold/clammy Medications
Menopause? Hot flushes  perspiration noted taken.
Birth control pills. Face :  flushed rashes
Hormonal replacement twitching
taken.  paralysis
EDC, onset of OB-GYNE
contractions. Have FHT: ______bpm
membranes ruptured? Rate of contractions; ____per
min.
duration : ____________
Frequency: ___________.
 Intact membranes  not

 Vaginal bleeding  none

July 2010 CJVALEZA, RN, MAN 22
CJVALEZA, RN, MAN July 2010 22
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
5. REGULATORY
MECHANISMS Height of fundus: _____cms.
Fever before?, associated Char. of fundus: Results of blood
with? Any chills? Relief  firm  soft /boggy examination
measures? Appearance of lochia: indicative of
Menarche, interval, no. of  rubra  serosa  alba infection process.
days. LMP? Amount: _________ Medications
Menopause? Hot flushes  Breast enlargement taken.
Birth control pills.  tenderness
Hormonal replacement Male/female genitalia.
taken. (Describe char.) ___________
EDC, onset of
contractions. Have
membranes ruptured?

July 2010 CJVALEZA, RN, MAN 23

CJVALEZA, RN, MAN July 2010 23
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
6. HYGIENE
How often does patient General appearance, Toiletries use.
take a bath? Time? neat, dirty? Unkempt? Brand of soap,
Shampoo use? Often? Skin condition-scars, toothbrush/toothpas
te,
Brush teeth? Change lesions?
Shampoo use.
clothes, etc. HEAD: hair distribution
Allergies to soap, and texture.
shampoo. Scalp- secretions?
Any beliefs/practices Lesions? Dandruff,
related to personal pediculosis?
hygiene. Skull: contour, size
Nails- clean or dirty ,
short or long?
Mouth- clean? Odors?
Halitosis? Unpleasant
odor of patient?

July 2010 CJVALEZA, RN, MAN 24

CJVALEZA, RN, MAN July 2010 24
 PATTERNS OF
FUNCTIONING
7. ACTIVITY & EXERCISE
Usual exercise at home:
________ frequency & time
done:_________
 Joint stiffness experienced.
 Hx. Of gout  arthritis,
 Paralysis: _________
since when: _______
 Prosthetic/devises
 Aids to mobility: _________
July 2010
CLINICAL EXAMINATION OTHER SOURCES
Physical bearing, stature, gait, X-RAY results for
posture, movement, extent of fractures,
range of joint motion? dislocations. Lab
Limitations of movements?
results which
Fractures? Joint stiffness
Contracture deformities? would signify
Dislocation? Muscle pain? musculo-skeletal
Cramps? Amputated parts? abnormalities.
Use of crutches, cane, or
other walking aids.
Neck: symmetry of
musculature, abnormal
masses, swelling,
enlargement of thyroid
glands, presence of lymph
nodes, vein prominence,
scars, moles stiffness of neck?
CJVALEZA, RN, MAN 25
CJVALEZA, RN, MAN July 2010 25
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
8. REST AND SLEEP 
No. hours usually slept: ______ Looks tired Rest prescription
Time of arising and retiring: of physician
____ 
sleepy
 Insomnia 
eye bags/puffiness around
Daytime naps
How long:______ 
difficulty in sleeping
Favorite sleeping position; Possible cause: _________
 supine  prone  side-lying
No. of pillows used: ____pcs. Actual no. of hours slept:
 use Mosquito net ______
 Bedtime rituals
Describe: ___________ 
Interrupted sleep
 snores 
frequent yawning
 teeth grinding
 talks when asleep 
decreased attention span

July 2010 CJVALEZA, RN, MAN 26

CJVALEZA, RN, MAN July 2010 26
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
9.COMMUNICATION AND
SPECIAL SENSES EYE: distribution of lashes, Results of sight and
condition of eyelids. Color of hearing tests.
Right handed left handed sclera, dryness or lacrimation.
Use of eye glasses Characteristics of conjunctiva,
 Hearing aids pupils, eye control movement,
lens, presence of ulcerations,
For how long the patient
abrasions, foreign body, eye
is wearing these?_______ infection, growth, cataract
Visual and auditory EARS: shape of pinna, legions,
disturbances: swelling, tenderness of mastoid
 yes  no process, external canal,
discharges, foreign bodies,
Speech disturbances: earache? Difficulty of hearing.
 yes  no NOSE: patency, condition of
septum, and turbinates,
Dialect or language
adenoids? Epistaxis?
spoken:_______ VOICE: manner of talking?
Mannerisms? Coherence of
expressions, presence of glasses
and contact lenses, hearing aids
and speech defects.
July 2010 CJVALEZA, RN, MAN 27
CJVALEZA, RN, MAN July 2010 27
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
10.COGNITION &
PERCEPTION (sensory) Oriented:
Results of

person 
time 
place. Level
HX of convulsions neurological
 yes  no of consciousness exams. Or tests
Hx of loss of consciousness
 yes  no alert restless 
lethargic
Hx of epilepsy comatose(GCS) : ____

 yes  no
onset (age): _____years old Suffering from seizures while in
Medications taken your care?  yes  no
 yes  no
Response to stimuli:
Tactile 
yes 
no
Verbal 
yes 
no
coherence of expression:

yes 
no

July 2010 CJVALEZA, RN, MAN 28

CJVALEZA, RN, MAN July 2010 28
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
11. PAIN AND 
DISCOMFORT
Check the
Pain and discomforts Facial grimace physician’s
frequently experienced:
guarding
 record for
 yes  no symptoms of
Describe manifestation: Pain scale (0-10): ____
which the
_________
Relief done: _____________
affect other patterns: patient
Does he know the cause? 
yes 
no complains.
 yes  no Medications
Discomfort felt: taken.
Describe:______________

yes 
no
Describe: ______

July 2010 CJVALEZA, RN, MAN 29

CJVALEZA, RN, MAN July 2010 29
 PATTERNS OF OTHER
CLINICAL EXAMINATION
FUNCTIONING SOURCES
12. RECREATION AND
DIVERSION

What is done for Any evidence of boredom? Presence of

fun?___________ 
yes 
none entertainment
Hobbies: ____________ appliances,
Interest he would like to Describe: ___________ gadget, devices.
pursue: What does he want to do to
Describe: _______
(Children) what is their pass his time?
favorite plaything? ________ ______________

July 2010 CJVALEZA, RN, MAN 30

CJVALEZA, RN, MAN July 2010 30
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
13. RELIGIOUS LIFE
Religious affiliation Religious medals worn Advices from
 Roman Catholic
yes  none religious ministers.
Islam
others: ___________ Describe: _______
Need for religious
Religious belief and counselor:
practices (esp. those
that may affect his care  yes  none
and health), diet, days Ability to meet own spiritual
of worship, holy day: needs.
describe ___________ yes  none

July 2010 CJVALEZA, RN, MAN 31

CJVALEZA, RN, MAN July 2010 31
 PATTERNS OF
CLINICAL EXAMINATION OTHER SOURCES
FUNCTIONING
14. COPING MECHANISMS
What is done when facing What are the patient’s Reports of psychiatric
stressful situation? : _________ attitudes? Mood? evaluation
What do you do when: How he is coping with his
Angry:___________________ illness?
Frightened:________________ Coping mechanisms observed
Whose advise is sought when during stressful
problems occurs? situation/circumstances. Post
parents 
 siblings natal pts; response to

spouse  motherhood.
others: ________ Ways of handling the baby(
case)

July 2010 CJVALEZA, RN, MAN 32

CJVALEZA, RN, MAN July 2010 32

PATTERNS OF FUNCTIONING
15. ROLE AND RELATIONSHIPS
(for Adult client)
Work role- type and hours of work.
Feelings about his work.
Family roles
Members of household
Social roles
Anybody special he wants to see?
Cultural prescriptions re: health care
and practices
CLINICAL
OTHER SOURCES
EXAMINATION
Support of family/friends
Behavior towards
roommates. Visitors, staff,
acceptances of sick role or
other role change. Need for
teaching and counseling.

July 2010 CJVALEZA, RN, MAN 33

CJVALEZA, RN, MAN July 2010 33
IV. Laboratory Study and
Other Diagnostic Procedure

Laboratory Normal
Date Result Interpretation Significance
Exam Values

July 2010 CJVALEZA, RN, MAN 34

V. Drug Study
NAME OF DRUG:
Generic
Brand
Classification
Mechanism of Action
Indication
Contraindications
Side effects and adverse reactions
Nursing responsibilities

July 2010 CJVALEZA, RN, MAN 35

 Drug Study for
Grand Case Presentation
Name of Patient: ________________________
Age: ____________ Sex: _____________
Diagnosis: _____________________ Attending Physician: _______________
Date Ordered: _____________________

Side
Dose, Nursing
Name of Mechanism Contraindi Effects and
Classification Frequency Indications Responsibi
Drug of Action cations Adverse
and Route lities
reactions

Reference(s): _____________________________
July 2010 CJVALEZA, RN, MAN 36
 VI. ANATOMY AND
PHYSIOLOGY

July 2010 CJVALEZA, RN, MAN 37

 VII. PATHOPHYSIOLOGY
Predisposing Factors: Contributing Factors:
Sex, Age, Race Diet
Congenital Defects Lifestyle
Heredo-familial Disease Environment

Precipitating Factors:

Signs and Symptoms

July 2010 CJVALEZA, RN, MAN 38

 VIII. Nursing Care Plan
Name of Patient: ___________________ Age: ______ Ward: __________
Chief Complaint: ________________________ Attending Physician: _______________

Nursing Expected Nursing

Cues Rationale Objective Rationale Evaluation
Diagnosis Outcome Interventions

Name of Student: ___________________ Reference/s:

July 2010 39
______________________ CJVALEZA, RN, MAN
IX. Discharge Plan
NURSING ORDERS DISCHARGE INSTRUCTIONS

Specify the prescribed take –home

medications, include health teaching
Medications regarding the drugs’ information

Specify applicable/advisable/permitted
Exercise exercise particular to the patient’s care

July 2010 CJVALEZA, RN, MAN 40

 IX. Discharge Plan

NURSING ORDERS DISCHARGE INSTRUCTIONS

Includes nebulization therapy, chest

physiotherapy
and other treatment related to patient’s
Treatment case that can be done at home.
Specify self care needs of patient at
home. Ex. Schedule of bathing, tooth
Hygiene brushing without compromising her
post-hospitalization condition.

July 2010 CJVALEZA, RN, MAN 41

 IX. Discharge Plan
NURSING ORDERS DISCHARGE INSTRUCTIONS

Return schedule to clinic after discharge

OPD for follow-up treatment and evaluation

Specify prescribed diet ex. DM,

Diet Hypertensive diet (enumerate to patient
foods to be taken)

Spirituality Enhance the patient’s religious belief

Name of Student: _________________________ Date: _____________

July 2010 CJVALEZA, RN, MAN 42
Related reading format
College of Nursing and Health Sciences
I. Print out of Related Reading sources –
published books, journals, website, magazines,
etc.
II. Summary of Related Reading (Brief)
III. Reaction/Critics
Personal Insight
Reaction from author’s point of view/compare/critic
Adaptability of literature to the present clinical set-
up/ application
Implications to nursing practice
V. Learning Insights
VI. Recommendations/Suggestions
July 2010 CJVALEZA, RN, MAN 44