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BIOGRAPHIC DATA Hospital No.: Ward: Name: Age: BW: Sex: BL: Birthday: Birthplace: Address: Religion: Mother’s Name: Age: Occupation: Father’s Name: Age: Occupation: Spouse’s Name: Age: Occupation: Admitting Diagnosis: Admitting Physician: Admitting Date: Time: C/C: Reason for Seeking Care: Sources of Data: Primary: Secondary:
PRESENT HEALTH HISTORY
PSYCHOSOCIOECONOMIC HISTORY
OVERVIEW OF THE DISEASE
FAMILY HEALTH HISTORY
Epithelial Cells ----- Mucus Threads None A. Urates Few Bacteria None Name: Age: Sex: OR No.: Physician: Date: HEMATOLOGY RESULT Category Normal Values Results Interpretation Hematocrit 0.39-0. WBC 4.5-11. Platelet Cunt 150- Segmentors 0.54-0. Lymphocytes 0.23-0. Monocytes 0.03—0.
PHYSICAL ASSESSMENT Name: Gender: Age: Date Examined: General Appearance: Vital Signs: T: PR: RR: BP: Assessment Normal Findings Findings Interpretation SKIN, HAIR, AND NAILS Assess for skin color, odor, and lesions Skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or black. No strong odor should be evident, and the skin should be lesions free Skin should be soft, warm, slightly moist with good turgor and without edema or lesions Inspect and palpate hair Hair is normally lustrous, silky, strong and elastic. Fine, downy hair covers the body. Scalp is clean and dry. Hair is smooth and firm. Inspect and palpate nails Nails are cleaned. Pink tones should be seen. Capillary refill of < secs.
Observe the condition of the lips, gums and teeth Gums appear pink and moist with tight margins to the tooth. 28 teeth. Lips are pink. Inspect nose Nose is midline in face, septum is straight and nares are patent. No discharge or tenderness is present No flaring of the nose Color is the same with the rest of the face THORAX Observe respiratory efforts The client does not use accessory muscle (trapezius and shoulders) muscles to breathing. The diaphragm is the major muscle at work. Normal respiratory rate: 12-20 per minute Palpate for tenderness and sensation Client reports no tenderness, pain or unusual sensation Palpate surface characteristics Skin and subcutaneous tissue are free of lesions and masses Auscultate for breath sounds and adventitious sounds No adventitious breath sound heard HEART Auscultate for murmurs Normally no murmurs are heard ABDOMEN Inspect for coloration of skin Abdominal skin may be paler than the general skin tone Inspect umbilicus Umbilicus is pink, no discharge, odor, redness or herniation. Umbilicus is midline at lateral line Percuss for tone Tympany predominates over the abdomen Palpate for masses and tenderness Abdomen is soft to palpation and without masses or tenderness MUSCULOSKELETAL Assess arms, Feet and legs are
hands, feet and legs symmetric in size, shape and movement. Extremities should be warm and mobile with adequate capillary refill of 2 seconds NERVOUS SYSTEM Test CN I (Olfactory) Client correctly identifies scent presented to each nostril. Test CN II (Optic) Client has 20/20 vision OD (right eye) and OS (left eye). Client reads print at 14 inches w/o difficulty. Test CN III (Oculomotor), IV (Trochlear), and VI (Abducens) Eyelid covers about 2 mm of the iris. Eyes move in a smooth, coordinated motion in all directions (the six cardinal fields). Bilateral illuminated pupils constrict simultaneously. Pupil opposite the one illuminated constricts simultaneously. Test CN V (Trigeminal) Temporal and masseter muscles contract bilaterally. The client identifies sharp and dull stimuli and light touch to forehead, cheeks and chin. Test CN VII (Facial) Client smiles, frowns wrinkles forehead, shows teeth, raises eyebrows and closes eyes against resistance. Movement are symmetrical. Test CN VIII (Vestibulocochlear) Weber test : heard equally well in both ears. Rinne test : AC>BC (air conduction is greater than bone conduction). Test CN IX (Glossopharyngeal) and X (Vagus) Uvula and soft palate rise bilaterally and symmetrically on phonation. Gag reflex intact. Client swallows w/o difficulty. Test CN XI (Spinal Accessory) There is symmetric, strong contraction of the trapezius muscles. Test CN XII (Hypoglossal) Tongue movement is symmetric and smooth. Bilateral strength is apparent.
Anu-ano an mga pagkaon it imo paborito? Pagkaon nga diri mo ayon? Paburito: Di-paburito: May ada ka ba mga gintutumar na vitamins? Hin-o it namamalit hit iyo pagkaon? Hin-o man it nagluluto ngan nag-aandam hit iyo pagkaon?
3. ELIMINATION PATTERN BOWEL HABITS Nakakapira ka uuro ha usa ka adlaw? Before: After: Kada san-o man? Before: After: Ano it kasagaran na kolor hit im baya? Before: After: Nagkuro ka na ba pag-uro?
Before: After: BLADDER HABITS Nakakapira ka iihi ha usa ka adlaw? Before: After: Ano kadamo it im ihi kada nim pag-iihi? Before: After: Ano it kasagaran nga kolor hit im gin-iihi? Before: After: Anu-ano na mga problema ha pag-ihi it imo naeksperyensyahan na? Before: After:
4. ACTIVITY-EXERCISE PATTERN Description of usual daily activities before hospitalization. Morning: Noon: Afternoon: Ano it imo mga buruhaton hini nga mga adlaw:
After:
6. COGNITIVE-PERCEPTUAL PATTERN Ano an imo natubtuban pag-eskwela? Kumusta it imo pakihuroharampang hit im igkasi tawo? 7. SELF-PERCEPTION-SELF-CONCEPT PATTERN Kumo usa nga babaye/lalaki maunanho mo maihuhulagway it imo kalugaringon? Ano tim mga nababarak-an ha im kinabuhi? Ano epekto tim sakit haim kalugaringon? Ano it imo mga hingyap panlawas? 8. ROLE RELATIONSHIP PATTERN Ano it imo katundanan ngan responsibilidad ha iyo pamilya? Kan kanay ka nakuha hin suporta ug kusog ha panahon nga nangingunahanglan ka hini? Ano nga pampamilya nga problema it imo yana pinag-aagian? Hin-o it pinakaimportante nga tawo para ha imo? 9. SEXUALITY-REPRODUCTIVE PATTERN Maunanho mo masisiring na ginbubuhat mo it imo katungdanan kumo usa nga babayr/lalaki?
Female: Ano an im eded han syahan ka nga gin-abot? Regular ba it imo regla kada bulan? Napira man kaadlaw? Male: Ano an im eada han nagpaturi ka? Ano an pamaagi han pagturi ha imo?
10. COPING-STRESS PATTERN Ano it epekto hit imo mga problema ha imo? Ha imo mga pan-adlaw-adlaw na uruhaton, ano epekto hini ha imo? 11. VALUE-BELIEF PATTERN Ano it pinakaimportante ha imo mga pamahiin? Ano/Hin-o it im pinagkukuhaan hin kusog ngan paglaum? Para ha imo, ano ka importante it pagtuo ngan pag-ampo ha Ginoo? Ano nga mga pamatasan o mga gintutuohan nimo an diri niyo pinagkakaasyahan hit imo pamilya?
