Father Saturnino Urios University

NURSING PROGRAM
Butuan City

DAILY OBJECTIVES

Name of Student: ______________________________________________________________________

Area of Assignment: _________________________________________ Date: ___________________

Student Objectives:
1.
2.
3.
4.
5.
Checked by: ___________________

Area of Assignment: _________________________________________ Date: ___________________

Student Objectives:
1.
2.
3.
4.
5.
Checked by: ___________________

Area of Assignment: _________________________________________ Date: ___________________

Student Objectives:
1.
2.
3.
4.
5.
Checked by: ___________________

CI’s COMMENTS:
 NURSING SYSTEM REVIEW CHART

Name: ________________________________________________________ Date: _____________

GENERAL DESCRIPTION: _______________________________________________________________
Vital Signs
Temperature: _______ Pulse Rate: ________ Respiratory Rate: _______ Blood Pressure: __________
Height: ____________ Weight: ___________ Observation: ____________________________________

Use “N” to indicate “normal” condition and “A” to indicate “altered” condition. Write your assessment
findings at right indicating the location of the problem.

HEAD __________ _____________________________________________________________

SKIN __________ _____________________________________________________________
LYMPH __________ _____________________________________________________________
EYES __________ _____________________________________________________________
EARS __________ _____________________________________________________________
NOSE __________ _____________________________________________________________
MOUTH __________ _____________________________________________________________
NECK __________ _____________________________________________________________
BREASTS __________ _____________________________________________________________
CHEST:
Inspection _____________________________________________________________
Palpation _____________________________________________________________
Percussion _____________________________________________________________
Auscultation _____________________________________________________________
CARDIOVASCULAR SYSTEM
Pulses _____________________________________________________________
Carotid _____________________________________________________________
Bronchial _____________________________________________________________
Radial _____________________________________________________________
Popliteal _____________________________________________________________
Dorsalis pedis _____________________________________________________________
Posterior tibial _____________________________________________________________
HEART
Inspection _____________________________________________________________
Palpation _____________________________________________________________
Percussion _____________________________________________________________
Auscultation _____________________________________________________________
ABDOMEN _____________________________________________________________
UTERUS _____________________________________________________________
KIDNEY _____________________________________________________________
GENITALIA _____________________________________________________________
BACK and SPINE _____________________________________________________________
RECTUM _____________________________________________________________
EXTREMITIES _____________________________________________________________
BONES and JOINTS _____________________________________________________________
NEURO- PSYCH
Behavior _____________________________________________________________
Mental Status _____________________________________________________________
Reflexes _____________________________________________________________
Motor _____________________________________________________________
Coordination _____________________________________________________________

Criteria for Evaluation

1.0 – All significant data accurately identified
1.1 – 2.0 – Most significant data accurately identified
2.1 – 3.0 – Some significant data identified
3.1 – 4.0 – Most significant data not identified
4.1 – 5.0 – Significant data generally not identified
 NURSING HISTORY AND ASSESSMENT
Geriatric Cases

PART A

Date of History Time of History Information

Any Medical Diagnosis

How has the patient been managing the above problem at home?

Other illnesses or conditions

Alcohol usage Last Physical Exam Any known allergies

Medication and Dosage Immunization Usual Times Time of Last Patient’s

(Prescribed and Non- Prescribed) Taken Dose Understanding of
Purpose

Subjective Data Objective Data

Limitations or restrictions related to: Level of orientation (alertness, ability to process
information, etc.)
Vision: ____________ Yes ________ No ________
Blurring: Yes ________ No ________
Others specify Glasses ______________
Appearance of eyes, ears ______________________
Last eye exam: ___________________________________________
Contact Lenses _________
Speech impairment __________________________
Artificial eye ___________
Hearing Aid ____________

Report of dyspnea, cough or orthopnea etc. Breath sounds, sputum, etc. Respiratory Rate
Depth and Quality

How often does the patient smoke?

 Subjective Data
Report of chest pain, numbness, tingling, etc.
Reports of anorexia, nausea, usual meal pattern
ability to chew and swallow, recent change in
weight, etc.
Therapeutic diet
Last dental exam:
Bowel habits, voiding pattern, hemorrhoids,
description of menstrual pattern if applicable
Reports of pruritus, eczema, psoriasis, etc.
Last self-breast exam
Report of pain, quality, location, precipitating
factors, duration and how pain is relieved
Reported sleep patterns and bedtime rituals
Describe members of support system or immediate
household (age, health status, etc.)
Patient’s response to change or stress
Religious beliefs and practices
Description of home environment
Objective Data
Peripheral pulses, capillary refill
Homan’s sign, edema, etc.
Temperature: Oral ________ Axillary ________
Rectal ________
Pulses: Apical _________ Radial _________
BP: Lying ______ Sitting ______ Standing _______
Skin turgor, appearance of tongue, condition of
teeth, etc.
Height ________ Weight _______ Dentures _______
BMI____________
Diaphoresis, bowel sounds, appearance of urine,
feces, vomitus, etc.
Inspection for rashes, open areas and abnormal nail
conditions, etc.
Note distribution and quality of hair or presence of
wig.
Facial grimacing, guarding of affected areas, etc.
(Note: There may be no observable signs with
chronic pain)
Observation of non-verbal behavior
Observed of non-verbal behavior
Any sign of mental illness
Description of work environment
 NURSING ASSESSMENT

1. Name: ____________________________________ Age: ____ Status: ______ Sex: ____ Nationality: ______
Address: ___________________________________________________ Occupation: __________________
Educational Level: _____________________________ Religion: _____________________________
2. Diagnosis: _______________________________________________________________________________
Date Admitted: ________________________ Blood Type: ___________
3. Operation/ Delivery: _______________________________________________________________________
4. Allergies (specify in red ink) : ________________________________________________________________
5. Mental State: 8. Activities: 12. Bladder/ Bowel 14. Diet/ Nutrition:
_____ conscious _____ ambulant ______ intake/ output_____ NPO
_____ drowsy _____ dangle & sit up ______ incontinence _____ clear liquids
_____ stuporous _____ bedrest with toilet ______ catheter/ Foley _____ general liquids
_____ unconscious privileges ______ straight/ suprapubic _____ soft full
_____ comatose _____ complete bedrest drainage _____ computed
_____ others _____ others ______ colostomy _____ ability to eat
6. Motor status: 9. Hygiene & Comfort 13. Tubes 15. Osteorized/ Formula
_____ normal _____ oral care ______ thora tubes __________________
_____ slurred speech ______ NGT __________________
_____ hemiplegia 10. Bath ______ tracheostomy
_____ paraplegia _____ nurse / SO ______ jejunostomy 16. Food idiosyncrasies
_____ paresis _____ partial ______ colostomy __________________
_____ complete ______ stump/ penrose drain _________________
7. Mood or affect ______ others
_____ calm 11. Perineal care 17. Drip feeding
_____ anxious _____________________ ______________________________________

SPECIAL PATIENT INFORMATION

18. _________ weight daily __________ PT/ OT

_________ BP q shift _________ Neuro v/s
__________ urine test __________ 24 – hour urine collection

Order Diagnostic / Laboratory Date Date IV Fluids / Blood Date

Examination Done Ordered Discontinued
Patient’s Name_________________________________________________________

PATIENT’S PROBLEM and PRIORITIZATION LIST

Problem Date Nursing Problem Date Date

Number Noted Reactivated Resolved