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MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City I. ASSESSMENT A. General Data Patients Initials: Address: Informant: Age: Date of Admission: Sex: Order of Admission: Date of Birth: No. of Days in the Hospital: Occupation: B. Chief Complaints C. History of present illness D. Past History: 1. Childhood Illness: 2. Adult Illness: 3. Immunization (date) 4. Previous Immunization (date) 5. Operations (include year) 6. Injury (include year) 7. Medications taken prior to confinement (6 months) 8. Allergies E. System Reviews: Gordons Eleven Functional Areas (Narrative form 1st Paragraph- previous health 2nd paragraph- present) F. Family Assessment (tabulated) PATIENT NOT INCLUDED.
Name Relation Age Sex Occupation Educational Attainment

G. Heredo-Familial Illness Maternal: H. Developmental History

Theorist

Paternal:
Age Task Patient description

I. Physical Examination Date & Time: Height Actual Height: Anthropometric Measurements: (for pedia 0-3 years old) Head Circumference: Chest Circumference: Abdominal Circumference: Temperature: PR: RR: BP: Regional Examination A. Skin Inspection: Palpation: B. Nails Inspection: Palpation: C. Head and Face Inspection: - A symmetrical, lesion-free skull - Symmetrical facial structures with normal variations in skin texture and pigmentation Palpation: - Ability to shrug the shoulders - No lumps or tenderness - Symmetrical strength in the facial muscles - Symmetrical sensation when you strike a wisp of cotton on each cheek D. Eyes Inspection: - No edema, scaling, or lesions on eyelids - Eyelids completely covering corneal when closed - Eyelid color the same as surrounding skin color - Palpebral fissures of equal height - Symmetrical, lesion-free upper eyelids that dont sag or droop when the patient opens his eyes - Evenly distributed eyelashes that curve outward - Globe of the eye neither protruding from nor sunken into the orbit Actual Weight: Ideal Body Weight:

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- Eyebrows are equal size, color, and distribution - Absence of nystagmus - Clear conjunctiva with visible small blood vessels and no signs of drainage - White sclera visible through the conjunctiva - Round, equal size that react to light and accommodation - Constriction of both pupils when you shine a light on one - Proper eye alignment - Parallel eye movement in each of the six cardinal fields of gaze Palpation: - No eyelid swelling or tenderness E. Ears Inspection: - Bilaterally symmetrical, proportionately sized auricles - Tip of ear crossing eye-occiput line - Long axis of the ear perpendicular to the eye-occiput line - Color match between the ears and facial skin - No signs of inflammation, lesions, or modules - No visible discharge from the auditory canal - A patent external meatus - Skin color on the mastoid process that matches the skin color of the surrounding area - No redness or swelling Palpation: - No masses or tenderness on the auricle - No tenderness on the auricle or tragus during manipulation - Either small, nonpalpable lymph nodes on the auricle or discrete, mobile lymph nodes with no signs of tenderness - Well-defined, bony edges on the mastoid process with no signs of tenderness F. Nose Inspection: - Symmetrical, lesion-free nose with no deviation of the septum or discharge - Little or no nasal flaring - No edema on the frontal and maxillary sinuses - Indentified familiar odors - Pink-red nasal mucosa with no visible lesions and no purulent drainage - No evidence of foreign bodies or dried blood nose Palpation: - No structural deviation, tenderness, or swelling on the external nose - No tenderness or edema on the frontal and maxillary sinuses G. Mouth and Pharynx Inspection: - Pink color of lips - No cracking, lesions or cyanosis - Symmetrical to facial structures - Ability to open mouth and close mouth easily - Visible salivary ducts with no inflammation - White, hard palate - Pink soft palate - Pink gums with tartar - All teeth are intact - Pink tongue that protrudes symmetrically and has no swelling, coating, ulcers r lesions - No lesions and inflammation on the posterior pharynx - Lesion-free tonsils Palpation: - Lips free from pain - No tenderness on the posterior and lateral surfaces of the tongue - No tenderness or nodules on the floor of the mouth H. Neck Inspection: - Unrestricted range of motion in the neck - No bulging of the thyroid - Symmetrical lymph nodes with no swelling - Non-visible jugular veins Palpation: - Mobile, soft lymph nodes with no tenderness - Symmetrical pulses in the carotid arteries - A palpable, symmetrical, lesion-free thyroid with no tenderness - Midline location of the trachea and absence of tracheal tenderness - No crepitus, tenderness, or lesions in the cervical spine I. Spine Inspection: Palpation: J. Thorax/Lungs Inspection: - Symmetrical side-to-side configuration of the chest - Normal chest shape, with no deformities - Quiet respirations with no use of accessory neck, shoulder, or abdominal muscles - No intercostals, substernal, or supraclavicular retractions

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- Symmetrically expanding chest wall during respirations - Normal adult respiratory rate - Regular respiratory rhythm, with expiration taking twice as long as respiration - Skin color matches the bodys complexion Palpation: - Warm dry skin - No tender spots or bulges in the chest - No assymetrical expansion, fremitus, or subcutaneous crepitation Percussion: - Resonant sound over the lungs Auscultation: - Loud, high-pitched bronchial breath sounds over trachea - Intense, medium-pitch bronchovesicular sound breath sounds over the mainstem bronchi, between the scapulae, and below the clavicles - Soft, breezy, low-pitched vesicular breath sounds over the most of the peripheral lung fields K. Cardiovascular/Heart Inspection: - No visible pulsations, except at PMI - No lifts or retractions in the four valve area of the chest wall Palpation: - No detectable vibrations or thrills - No pulsations except at the PMI and epigastric area Auscultation: - Lub (s1)-Dub (s2) sound - 1st heart sound (lub)- *mitral area (It sounds longer than s1 sounds) - 2nd heart sound (dub)- *aortic area (It sounds shorter, sharper, higher, and louder than S2 sounds) - No murmur L. Breast Inspection: Palpation: M. Abdomen Inspection: - Skin free from vascular lesions, jaundice, surgical scars, and rashes - Flat, round abdominal contour - Symmetrical abdomen - Umbilicus positioned midway between the xiphoid process and the symphysis pubis, with a flat or concave hemisphere - No variations in skin color - No apparent bulges - Abdominal movement apparent with respirations Auscultation: - High-pitched bowel gurgling sounds, heard every in all four quadrants of the abdomen - Vascular sounds heard through the bell of the stethoscope - No bruits, murmur, friction rubs, or other venous hums Percussion: - Tympany predominantly over hollow organs, including the stomach, intestines, bladder, abdominal aorta, and gallbladder - Dullness over solid masses including kidneys, liver, spleen, pancreas Palpation: - No tenderness or masses - Abdominal musculature free from tenderness and rigidity - No guarding, tenderness, distension, or ascites N. Extremities Inspection: - No gross deformities - Symmetrical body parts - Good body alignment - No involuntary movements - Smooth gait - Full range of motion in all muscles and joints - No pain in full ROM - No visible swelling or inflammation of joints or muscles - Equal bilateral limb length and symmetrical muscle mass Palpation: - Normal shape with no swelling or tenderness - Equal bilateral muscle tone, texture, and strength - No involuntary contractions or twitching - Equally strong bilateral pulses O. Genitals Inspection: P. Rectum and Anus Inspection: Q. Neurologic Exam - Ability to shrug the shoulders (CN XI) - Symmetrical strength in the facial muscle (CN V and VII) - Closing of both lids when you stroke each cornea with a wisp of cotton (CN V)

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- Ability to purse lips and puff out cheeks (CN VIII) - Ability to move tongue easily and without tremor (CN XII) - Uvula moves upward when the patient says ah and a gag reflex that occurs when a tongue blade touches the posterior pharynx (CN IX and X) J. PERSONAL/SOCIAL HISTORY Habits: Rank in the family: Vices: Travel: Lifestyle: Educational Attainment: Social affiliation: Clients usual day like: K. ENVIRONMENTAL HISTORY (Living/Neighborhood circumstances) L. OB/GYNE HISTORY (FOR FEMALES ONLY) Menarche (age): When: Amount and Characteristics: Duration: Associated Symptoms: Deliveries: G __P__ Operations: OB Score: T __P__A__L__ M. PEDIATRIC HISTORY MATERNAL AND BIRTH HISTORY Birth Date: Hospital: Birth Weight: Type of Delivery: Condition after birth: Mother: - Complications after delivery: - Anesthesia drug during labor: - Exposure to Teratogenic Agents during Pregnancy: Neonates ONLY: - Neonatal History: - Feeding History: - Type of Feeding: N. PATHOPHYSIOLOGY A. Theoretical Based B. Client Based O. LABORATORY RESULT OR FINDINGS (date and time)
Laboratory (date) Normal Value Result Interpretations/Significance

P. DRUG STUDY (client based)

Drugs Date Ordered: Generic Name: Classification: Dosage: Indications Contraindications Actions Drug Interactions Side Effects/Adverse Reaction (per system) Nursing Consideration Assessment: Implementation: Patient/Family Teaching:

Q. LIST OF PRIORITY PROBLEM R. NURSING CARE PLAN

Cues/Needs Subjective Data: Objective Data: Nursing Diagnosis Rationale Goals and Objectives Interventions Rationale Evaluation

S. ONGOING APPRAISAL (A comprehensive summary of patients daily health status to include medications, procedures; Laboratory done in collaboration with other members in Healthcare team.) T. DISCHARGE PLAN M- Medication E- Exercise T- Treatment H- Health Education O- OPD follow-up D- Diet S- Signs and Symptoms

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