MANUAL REQUIREMENT GUIDE Note: Submit Draft on Friday

I. INTRODUCTION (3-5 paragraphs)

Provide general background of the problem, how the problem affects the people, the organization and the profession,
in what way the problem will be solved? Incidence and prevalence of the problem?
II. NURSING HEALTH HISTORY (Narrative Form)
Biographic Data

Chief Complaints

History of Present Illness

Past Medical History

Family history of Illness

Genogram (starts from the grandparents of the patient, should also have legend)

Menstrual and Obstetric History

Lifestyle/Activities of Daily Living

Social Data

Psychological Data

III. GORDON’S FUNCTIONAL HEALTH PATTERN and REVIEW OF SYSTEMS

- Must have data before and upon admission
- Summarize all the patterns at the end of table

GORDON’S BEFORE DURING

FUNCTIONAL HEALTH
PATTERN
1. Health Perception /
Health Management

2. Nutritional - Metabolic

3. Elimination

4. Activity – Exercise
 5. Sleep – Rest

6. Cognitive –
Perceptual

7. Self – Perception /
Self Concept

8. Role - Relationship

9. Sexually –
Reproductive

10. Coping /
Stress Tolerance

11. Value - Belief

Summary:

IV. PHYSICAL ASSESSMENT (Head to Toe) and REVIEW OF SYSTEMS

PHYSICAL FINDINGS REVIEW OF SYSTEMS

ASSESSMENT

SKIN

HAIR
 HEAD

FACE

EARS

EYES

NOSE

MOUTH

NECK

CHEST (Anterior /
Posterior)

ABDOMEN

UPPER
EXTREMITIES

LOWER
EXTREMITIES

GENITALS

V. CRANIAL NERVE ASSESSMENT (For Neurological involvement only)

 CRANIAL NERVE FINDINGS SIGNIFICANCE
1 OLFACTORY

2 OPTIC

3 OCULOMOTOR

4 TROCHLEAR

5 TRIGEMINAL

6 ABDUCENS

7 FACIAL

8 VESTIBUCOCHLEAR

9 GLOSSOPHARYNGEAL

10 VAGUS

11 SPINAL ACCESSORY

12 HYPOGLOSSAL

VI. LABORATORY/ DIAGNOSTIC RESULTS (Can attach the results in a separate sheet)

LABORATORY Date Taken Normal Values Result Significance Nursing Responsibilities

EXAM
 DIAGNOSTIC Date Taken Result / IMPRESSION Significance Nursing Responsibilities
EXAM

VII. SUMMARY OF MEDICATIONS/IV , BLOOD TRANSFUSIONS, TREATMENTS (ACTUAL; According to date and
specify date of discontinuation)
VIII. ANATOMY AND PHYSIOLOGY (Review of the organ and its function, direct to the illness); but if there is multiple
organ involvement must also include.
IX. PATHOPHYSIOLOGY OF THE DISEASE (disease process, complications, prognosis)
X. MEDICAL MANAGEMENT

MEDICAL IDEAL (Book) ACTUAL (Done or Not Done)

MEDICATIONS
1. Duphaston
Purpose

LABORATORY
1. CBC
Purpose

DIAGNOSTICS
 DIET

TREATMENTS

XI. SURGICAL MANAGEMENT

SURGICAL (INVASIVE OR NON- IDEAL (Book) ACTUAL (Done or Not Done)
INVASIVE)
(write the purpose)

XII. OUTLINE OF NURSING MANAGEMENT

GOAL Focus Nursing Interventions

Health Promotion

Disease Prevention
 Curative

Rehabilitation

XIII. DRUG STUDY

XIV. NCP
XV. DISCHARGE PLAN
XVI. REFERENCES