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College of Nursing: Ateneo de Zamboanga University
College of Nursing: Ateneo de Zamboanga University
COLLEGE OF NURSING
General Objectives:
Acquisition and application of knowledge, skills, and attitude through the utilization of nursing process in
the care of patients with infectious and inflammatory diseases with emphasis on health promotion,
prevention, and maintenance of health.
Learning Objectives:
At the end of the 24 hours of Related Learning Experience, I will be able to:
Plan of Activity
Time Activities
Day 1
6:45 am – 7:00 am - Arrival at the waiting area
3:00 pm - Dismissal
MENTAL STATUS
APPEARANCE
BEHAVIOR
Level of Consciousness:
( / ) Awake ( / ) Alert ( ) Lethargic
( ) Drowsy ( ) Stupurous or unresponsive
( ) Aware and responsive of internal and external stimuli
Facial Expression: Sad Speech: Normal
Mood: Restless Affect: N/A
COGNITION
THOUGHT PROCESS
INTEGUMENTARY SYSTEM
Ateneo de Zamboanga University
COLLEGE OF NURSING
SKIN
INSPECTION
Color: ( / ) Normal ( ) Flushed ( ) Pale ( ) Dusky
( ) Cyanotic ( ) Jaundiced ( ) Others: _________________________
Texture:Smooth Tone:
Lesions: ( ) Yes, site: _______ ( / ) No
PALPATION
Moisture: Temperature: 38°C
Turgor: _______________________
Edema: ( / ) Absent ( ) Present, site: _______________________
( ) Mild ( ) Moderate ( ) Severe
Pruritus: ( ) Yes, site: _________________ ( / ) No
Wound incision/pressure sore site: N/A Dressing type: N/A
Odor: ( / ) None ( ) Mild ( ) Foul
Drainage/Exudates: ( ) Serous ( ) Sanguinous ( ) Serosanguinous
Color: ( ) Yellow ( ) Creamy ( ) Green ( ) Beige/tan
NAILS
INSPECTION
Color: Pinkish Texture: Smooth Configuration: Rounded Symmetry: Symmetrical
Cleanliness: Well-trimmed
PALPATION
Temporal Artery: Normal
Cranium: Normal Scalp: Normal
Hair Texture: Smooth
Maxillary & Frontal Sinuses: Normal
EYES
INSPECTION
Conjunctiva: R: Normal L: Normal Sclera: R: Normal L: Normal
Cornea: R: Normal L: Normal Iris: R: Normal L: Normal
Ptosis: R: None L: None
Visual Fields: R: Normal L: Normal
Extraocular movements: : R: Normal L: Normal
Pupil: Color: R: Black L: Black Size: R: Equal L: Equal
Response to Light & Accommodation: R: ______ L: ______
NOSE
INSPECTION
External Nose: Normal
Ateneo de Zamboanga University
COLLEGE OF NURSING
MOUTH
INSPECTION
Mouth & Throat Mucosa: Normal Tongue: Pinkish
Teeth and Gums: Complete teeth, symmetrical Floor of Mouth: Normal Palate: ______
Uvula: ______
Lesions and Ulcers: ( ) Yes, site: ____________ ( / ) No
Salivary Glands: ______
FACE
INSPECTION
Spasms: ( ) Yes, site: __________ ( /) No
Tics: ( ) Yes, site: __________ ( /) No
Lesions: ( ) Yes: ( ) Mild ( ) Moderate ( ) Severe ( /) No
Facial Paralysis: ( ) Yes R: _________ L: _________ (/ ) No
EARS
INSPECTION
Tympanic membrane: R: Intact ( /) Yes ( ) No L: Intact ( /) Yes ( ) No
Tragus of Ear: R: ______ L: ______
Canal: R: ______ L: ______
Lesions: ( ) Yes, site: ___________ ( / ) No
Discharges: ( ) Yes, amount: ________ ( ) Left ( ) Right ( ) Both ( / ) No
NECK
PALPATION
Thyroid gland size: Normal Shape: Normal
Tenderness: None Nodules: None
Position of Trachea: ______
Cervical Lymph Nodes: None
RESPIRATORY SYSTEM
LUNGS
INSPECTION
Respiration Rate: 32bpm
Pattern: ( ) Shallow ( / ) Dyspnea ( ) Tachypnea ( ) Shortness of Breath
Chest Symmetry: ( / ) Even ( ) Uneven
Chest Deformities: ( ) Scoliosis ( ) Kyphosis ( ) Kyposcoliosis
PALPATION
Chest: ( ) Masses, site: ____________
( ) Bulges, site: ____________
CARDIOVASCULAR SYSTEM
NECK VESSELS
PALPATION
Carotid Artery: R: Normal L: Normal
AUSCULTATION
Carotid Arteries: Bruits: ( / ) Absent ( ) Present
Jugular Vein Distention: ( ) Yes: _______cms. ( / ) No
HEART
INSPECTION
Point of Maximal Impulse (PMI): ______
Thrills: ( ) Present ( / ) Absent
PALPATION – Perfusion: Capillary Refill:_seconds
Murmurs: ____
PULSES
( ) Regular ( / ) Strong ( ) Irregular ( ) Weak ( ) Absent
( ) Doppler ( ) Pacemaker
Radial: R: _______ L: _______
Pedal: R: ____________ L: ____________
Apical: R: ____________ L: ____________
BP: R: 110/70 L: 110/70
GASTROINTESTINAL SYSTEM
Ateneo de Zamboanga University
COLLEGE OF NURSING
Mouth: ______
Throat: ______
ABDOMEN
INSPECTION
Contour: Flat
Symmetry: Symmetrical
Gastrostomy (specify): N/A
AUSCULTATION
Bowel sounds:( ) High-pitched & Gurgling ( ) Hyperactive
( ) Low-pitched ( ) Hypoactive
( ) Tympany
Rate: _ per minute
PERCUSSION
Notes: ____________________________ Site:__________________________________
PALPATION
Abdomen: ( ) Tender( / ) Soft/Non-Tender ( ) Firm ( ) Rigid
Mass: ( / ) No ( ) Yes
Ascites: ( / ) No ( ) Yes
Girth: ________________ Inguinal Area: Normal
MUSCULO-SKELETAL SYSTEM
INSPECTION
Symmetry: Normal
Deformities: N/A
Others: _________________
Peripheral pulses:
Upper Extremities: Radial: R: ______ L: ______
Ulnar: R: ______ L: ______
Brachial R: ______ L: ______
Lower Extremities: Popliteal: R: ______ L: ______
Dorsalis Pedis: R:_____ L: ______
Posterior Tibia:R: ______ L: ______
Edema: ( ) Yes ( )Pitting (Grade) _________ ( / ) No
Temperature: _______________________ Site: __________________________
RANGE OF MOTION: ( / ) Yes ( ) No, area: _________________
Deformity: ______________________________________________________________
Discrepancy in Extremity (Leg) Length ( )Yes ______________ ( / ) No
PALPATION
( ) Musculature ________________ ( ) Body articulation_____________________
( ) Crepitations ________________ ( ) Heat_____________________________( ) Swelling
____________________ ( ) Tenderness_______________________
Normal ROM of extremities: ( / ) Yes ( ) No
( ) Weakness ( Paresis) ( ) Paralysis
( ) Contractures ( ) Joint Swelling
( ) Pain: ( ) Bone Pain ( ) Muscle Pain ( ) Joint Pain
( ) Others: __________________________________________
Ateneo de Zamboanga University
COLLEGE OF NURSING
NEUROLOGIC SYSTEM
CRANIAL NERVES
Olfactory Nerve (CN I)
Normal
Optic Nerve (CN II)
Normal
Oculomotor (CN III)
Normal
Trochlear (CN IV)
Normal
Trigeminal Nerves (CN V)
Abducens Nerve (CN VI)
Normal
Facial Nerve (CN VII)
Normal
Acoustic Vestibulocochlear Nerve (CN VIII)
Normal
Glossopharyngeal Nerve (CN IX)
Normal
Vagus Nerve (CN X)
Normal
Spinal Accessory Nerve (CN XI)
Normal
Hypoglossal Nerve (CN XII)
Normal
CEREBELLAR FUNCTION
SENSORY SYSTEM
Discriminate Light Pain: ( ) Yes ( ) No
Detect Vibration: ( ) Yes ( ) No
Discriminate Light Touch: ( ) Yes ( ) No
Detect Temperature: ( ) Yes ( ) No
Detect Stereognosis: ( ) Yes ( ) No
Detect Graphesthesia: ( ) Yes ( ) No
Two-Point Discrimination: ( ) Yes ( ) No
SUPERFICIAL REFLEXES
GENITOURINARY
PERIANAL REGION
INSPECTION
PALPATION
( ) Rectal Masses
MALE GENITALIA
INSPECTION
Hair Distribution: Even
Penis: Dorsal Vein: ( ) Yes ( ) No
Urethral Meatus Appearance: _________________________________________
Bumps: ( ) Yes, site: ___________ ( / ) No
Blisters: ( ) Yes, site: ___________ ( / ) No
Lesions: ( ) Yes, site: ___________ ( / ) No
Redness: ( ) Yes, site: ___________ ( / ) No
Scrotum: R: ____________ L: ____________
Urine: Color: Yellowish Character: N/A
Frequency per day: N/A Amount: N/A
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): ______________________
Others (specify): _________________________
Ateneo de Zamboanga University
COLLEGE OF NURSING
FEMALE GENITALIA
INSPECTION
Mons Pubis: _____ Labia Majora: ____
Labia Minora:_____ Clitoris:_____
Vagina:_____ Urinary Meatus: _____
Skene’s and Bartholin’s Glands: ______
Urine: Color: ____________ Character: ______
Frequency per day: ___________ Amount: ___________________
( ) Anuria ( ) Hematuria ( ) Dysuria ( ) Incontinence
( ) Catheter (Type): _________________ Other:____________________
LMP: ______ ( ) Vaginal Discharges: __________________________________
Menstrual Problems:
( ) Amenorrhea ( ) Dysmenorrhea ( ) Menorrhagia
( ) Metrorrhagia ( ) Pre Menstrual Syndrome
Others (specify) ______________________________________
Age of Menarche:_ Length of Cycle: ________
Menopause: ___________________Last Pap Smear: ____________________
Monthly Breast Self Examination ( ) Yes( ) No
Method of Birth Control: _____________________________
Obstetrical History: _________ AOG ________
POP: ______ Weight: ________ FT _______ FHT_______
Leopold’s Maneuver: ________________ Presentation: ___________________
Urine Test Result: ___________________ Pregnancy Test:
( ) Albumin _______ ( ) Sugar ________
( ) Protein _______ ( ) RBC ________ ( ) Pus ________
Bleeding: ( ) Yes, amount: ___________ ( ) No
Uterine Discharges:
Rubra: Color ________ Amount________ Odor________
Serosa: Color_______ Amount________ Odor_________
Alba: Color_______ Amount________ Odor_________
PSYCHOSOCIAL
Recent Stress: Present health condition
Coping Mechanism: N/A
Support System: Family
Calm: ( ) Yes____________________ ( / ) No______________________
Anxious: ( / ) Yes____________________ ( ) No______________________
Angry: ( ) Yes____________________ ( / ) No______________________
Withdrawn: ( ) Yes____________________ ( / ) No______________________
Irritable: ( ) Yes____________________ ( / ) No______________________
Fearful: ( / ) Yes____________________ ( ) No______________________
Religion: Muslim Restrictions:_________________
Feeling of Helplessness: ( ) Yes ( / ) No
Feeling of Hopelessness: ( ) Yes ( / ) No
Feeling of Powerlessness: ( ) Yes ( / ) No
Ateneo de Zamboanga University
COLLEGE OF NURSING
NUTRITION
General Appearance: ( ) Well Nourished ( ) Malnourished
( ) Emaciated ( ) Other
Body Built: Normal Weight: 55 kg Height: N/A
Diet: N/A Meal Pattern: N/A
( / ) Feeds Self ( ) Assist ( ) Total Feed
PAIN ASSESSMENT
Location of pain: N/A Frequency: N/A
Intensity Pain Scale(0-10): N/A Quality: N/A
Onset: (When did your pain started?) 1 week
Duration: N/A Body Reaction: Fever associated with loss of appetite, dry cough
and colds
Alleviating Factors: N/A
Precipitating factors N/A
Special Assessment Devices
( ) Wheelchair ( ) Contacts ( ) Venous Access device
( ) Braces ( ) Hearing aid ( ) Epidural catheter
( ) Cane/ Crutches ( ) Prosthesis ( ) Walker
( ) Glasses
Others:____________________________________________________________
SELF-CARE
Ateneo de Zamboanga University
COLLEGE OF NURSING
PATIENT EDUCATION
( ) Safety / Restraint Use ( / ) Signs & Symptoms to Report
( / ) Ordered Therapies ( / ) Lifestyle Change
( / ) Diagnosis / Disease ( ) Rehabilitation Measures
( ) Pain Management ( ) Hygiene / Self care
( ) Hospital Referrals ( / ) Diet or Nutrition
( ) Community Referral ( ) Mobility / Ambulation
( / ) Medication
MEDICATION:
Cefixime 400mg/tab (1 tab OD for 3 days)
Montelukast 10mg/tab (1 tab OD HS for 14 days)
Cetirizine 10 mg/tab (1 tab OD for 30 days)
Sodium Ascorbate + Zinc tab (1 tab OD for 30 days)
NAC sachet (1 sachet + ½ glass of water OD for 7 days)
DIET:
Eat Nutritious Food
HEALTH TEACHINGS:
Always wear mask and face shield
TCB after 3 days for follow up
Ateneo de Zamboanga University
COLLEGE OF NURSING