Cebu Institute of Technology University

College of Nursing
Nursing History And Physical Assessment
I.

PATIENTSS PROFILE
Name of the Patient:___________________________
Name of the Hospital: ____________Ward no:___ Bed no:___
Age: _____ Sex:_______ Weight:________ Height:______
Civil Status: __________ Religion: ______________________
Address: ___________________________________________
Date of Admission: _____________ Attending Physician:

PATIENTS MEDICAL HISTORY

1. Immunization received:___________________________
2. Allergies: Food:_____________ Drugs:______________
3. Heredo- Familial Disease:_________________________

Others:__________________________________
4. Previous Surgery: _______________________________
5. Past Medical History: ____________________________
6. Recent Exposure to Communicable Disease: __________

Current Medication List:

Name of Drug

Dose

Route of
Administration

Frequency

II.

ADMISSION DATAS:
Date Admitted: _________________________
Time: _________________________________
Mode of Admission: _____________________
Source of Information:
Patient: _______________
Parents:_______________
Family Members: _______________
Relatives: _________________
Problems/ Urgent Need on Arrived: _________________________
Action Taken: __________________________________________
Admitting Diagnosis: ____________________________________

VITAL SIGNS ON ADMISSION:

Temperature

Pulse Rate

Respiratory
Rate

Blood
Pressure

Remarks

VITAL SIGNS ON ASSESSMENT:

Temperature

Pulse Rate

Respiratory
Rate

Blood
Pressure

Remarks

III.

PHYSICAL ASSESSMENT

BODY PART

SKIN

HAIR

NAILS

HEAD

FACE

EARS

EYES

NOSE

SINUSES

MOUTH

ASSESSMENT
FINDINGS

REVIEW OF
SYSTEMS

BODY PART

THROAT

NECK

BREAST AND
AXILLAE

HEART AND
PERIPHERAL
VESSELS

UPPER
EXTREMITIES

ABDOMEN

ANUS AND
RECTUM

GENITALS

LOWER
EXTREMITIES

ASSESSMENT
FINDINGS

REVIEW OF
SYSTEMS

IV. CRANIAL NERVE ASSESSMENT

CRANIAL NERVE

TYPE

FUNCTION

I. OLFACTORY

SENSORY

SMELL

II. OPTIC

SENSORY

VISION &
VISUAL
FIELDS

III.
OCULOMOTOR

MOTOR
EXTRA
OCULAR EYE
MOVEMENTS

SPECIFICALLY
MOVES
EYEBALL
DOWNWARD
AND
LATERALLY

IV. TROCHLEAR

MOTOR

V. TRIGEMINAL

SENSORY

SENSATION OF
FACIAL
SKIN &
ANTERIOR
CAVITY

VI.ABDUCENS

MOTOR

MOVES EYE
LATERALLY

ASSESSMENT
RESULT

CRANIAL NERVE TYPE

FUNCTION

VII. FACIAL

MOTOR &
SENSORY

FACIAL
EXPRESSION

SENSORY

EQUILIBRIUM

MOTOR
&
SENSORY

SWALLOWING
ABILITY;
TONGUE
MOVEMENT
AND TASTE

VIII. AUDITORY
VESTIBULAR
BRANCH

IX.
GLOSSOPHARYNGEAL

SENSATION OF
PHARYNX
& LARYNX;
SWALLOWING
VOCAL CORD
MOVEMENT

X. VAGUS

MOTOR
& SENSOR

XI. ACCESSORY

MOTOR

HEAD
MOVEMENT
SHRUGGING
OF SHOULDERS

XII.
HYPOGLOSSAL

MOTOR

PROTRUSION
OF TONGUE:
MOVES UP &
DOWN AND
SIDE TO SIDE

V.

GORDONS HEALTH PATTERN

ASSESSMENT
RESULT

HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

NUTRITIONAL- METABOLIC PATTERN

ELIMINATION PATTERN

ACTIVITY EXERCISE PATTERN

SLEEP-REST PATTERN

COGNITIVE-PERCEPTUAL PATTERN

SELF PERCEPTION- SELF CONEPT PATTERN

ROLE-RELATIONSHIP PATTERN

SEXUALLY-REPRODUCTIVE PATTERN

COPING-STRESS MANANGEMENT PATTERN

VALUE-BELIEF PATTERN