UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01

España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13

Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
WORKSHEET B ODC
rev 01Form 1A
5/24/13
Actual
ODC Delivery
Form 1Form
A
Actual Delivery Form
PHYSICAL ASSESSMENT

AREAS OF ASSESSMENT FINDINGS INTERPRETATION

1. Gross Assessment
a. Weight
b. Height
c. Body Built
d. Gait/Posture
e. Personal Hygiene

2. Skin
a. Color
b. Turgor
c. Continuity/Texture
d. Presence of lesions

3. Head
a. Skull
b. Scalp
c. Hair

4. Eyes
a. symmetry
b. Visual Activity
c. Peripheral vision
d. Papillary reflex
e. Sclera
f. Conjuctivitis
g. Others

5. Face
a. Symmetry

6. Ears
a. Texture
b. Symmetry
c. Discharge
d. Others

7. Nose
a. Discharge
b. Others

8. Mouth
a. Lips and gums
b. Teeth
c. Mucus lining
d. Tonsils
 UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01
España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13
Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
9. Neck ODC
rev 01Form 1A
5/24/13
a. Movement Actual
ODC Delivery
Form 1Form
A
b. Lymph node Actual Delivery Form
c. Others

10. Chest and Lungs

a. Symmetry
b. Shape and movement
c. Others

11. Breast
a. Size, symmetry, shape
b. Any mass/lesions
c. Others

12. Heart
a. Heart sounds

13. Abdomen
a. Shape

14. Extremities
a. Symmetry
b. Mobility
c. Muscle tone
d. Skin temperature
e. Joints

15. Neurologic Assessment

a. Level of consciousness
b. Gross motor function
c. Sensory function
d. Others

Activities of Daily Living

a. Nutrition
b. Elimination
c. Rest and sleep

Lifestyle
a. Personal habits
b. Recreations/hobbies
c. Occupation
 UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01
España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13
Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
ODC
rev 01Form 1A
5/24/13
Actual
ODC Delivery
Form 1Form
A
WORKSHEET C
Actual Delivery Form

FAMILY COPING INDEX

FAMILYSURVEYED:________________________________________

ADDRESS:_______________________________________________

AREAS OF ASSESSMENT SCORE JUSTIFICATION

1.Physical Independence

2. Therapeutic Competence

3. Knowledge of health condition

4. Application of principles of personal

and hygiene

5. Healthcare attitudes

6. Emotional competence

7. Family living patterns

8. Physical Environment

9. Use of community facilities

 UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01
España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13
Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
ODC
rev 01Form 1A
5/24/13
Actual
ODC Delivery
Form 1Form
A
WORKSHEET D Actual Delivery Form

FAMILY HEALTH PROBLEMS IDENTIFIED

FAMILYSURVEYED:__________________________________________________________________

ADDRESS:__________________________________________________________________________

            DATA        STANDARD         HEALTH PROBLEM AND CAUSE

        GATHERED

Health Deficit

Health Threat

Foreseeable Crisis

Wellness State
 UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01
España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13
Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
ODC
rev 01Form 1A
5/24/13
Actual
ODC Delivery
Form 1Form
A
Actual Delivery Form
WORKSHEET E
PRIORITY SETTING

Health Criteria/Scale Score Justification

Problem
 UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO01
España Boulevard, Sampaloc, Manila, Philippines 1015 rev 01 5/24/13
Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 1 A
Actual Delivery Form
Accredited by PACUCOA, Level IV Accredited Status UST:A012-00-FO01
rev 01 5/24/13
UST:A012-00-FO01
ODC
rev 01Form 1A
5/24/13
Actual
ODC Delivery
Form 1Form
A
Actual Delivery Form

WORKSHEET F
FAMILY NURSING CARE PLAN

HEALTH FAMILY GOAL OBJECTIVES INTERVENTIONS FAMILY RESOURCES OUTCOME

PROBLEM NURSING OF OF CARE NURSE REQUIRES OF
PROBLEM CARE CONTACT EVALUATION