Christ the King College
Gingoog City
Nursing Program
Name of Student: ________________________________ Date: ______________
Patient Hospital No. _________________ Patient Medical Record: ______________
Last Name: First Name: Middle Name:
Age: Sex: Nationality: Religion: Civil Status: Room Bed
No.
Address:
Contact No.
Chief Complaints: Date Admitted: Time Admitted:
Attending Physician:
Admission Impression:
Prognosis:
Vital Signs and Intake & Output Record
Date
Temperature
Blood Pressure
Heart Rate
Respiratory Rate
Intake
Output
Weight
Date Medication Remarks Date Time IV Date/Time Remarks
Ordered Ordered Started Fluids
Date Diet Remarks Date Laboratory Exams Remarks
Ordered Ordered
Date Nursing Measures and Treatment
Ordered
Christ the King College
Gingoog City
Nursing Program
Client Data Form
Name of Student: ___________________________ Date: ______________
Year Level: ________________ Group: __________ Area: ______________
CLIENT’S INFORMATION
Last Name: First Name: Middle Name:
Age: Sex: Nationality Religion Civil Status Room/Bed #
Address:
Contact Number:
Occupation: Date Admitted Time Admitted:
Attending Physician Reason for Hospitalization(client quote)
Admission Impressions:
Prognosis:
Family History (narrative):
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Personal History (narrative):
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Admission Data
Client is form: Mode of Admission:
Home: __________________ Ambulatory: ______________
Doctor’s Clinic: ___________ Wheelchair: ______________
School: _________________ Stretcher: ________________
Work: __________________ Others: __________________
Other Hospital: ___________ _______________________________
Others: _________________ _______________________________
________________________ _______________________________
________________________ _______________________________
Accompanied by: Valuables:
________________________________ None: ______
Laboratory results from outside: With Client : ______
________________________________ Given to Relatives: ______
_ Lists: __________________________
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_ _______________________________
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_ _______________________________
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_ _______________________________
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Person to notify in case of emergency: _______________________________
Name: _________________________
Address: _______________________
_______________________________
Contact #: ______________________
ASSESSMENT TOOL
VITAL SIGNS
Temperature: ____________ Axilla/ Oral
Pulse: __________________Radial/ Brachial
Apical Pulse: ____________
Respiration: _____________
Blood Pressure: __________Standing/Sitting/Lying Time BP taken: ______
Height: _________________ Measured/ Estimated
Weight: _________________Measured/ Estimated
ALLERGIES/SENSITIVE TO:
Any Allergy to food/Medicine/Latex/Others? ______Yes _______No
If YES, Please specify: ________________________________________________
Have used Blood Products? ______ Yes ________No
Reactions? ______ Yes ________No
CRANIAL NERVE ASSESSMENT
Cranial Nerve I ________________________________________________________
Cranial Nerve II ________________________________________________________
Cranial Nerve III ________________________________________________________
Cranial Nerve IV ________________________________________________________
Cranial Nerve v _________________________________________________________
Cranial Nerve VI ________________________________________________________
Cranial Nerve VII ________________________________________________________
Cranial Nerve VIII ________________________________________________________
Cranial Nerve IX _________________________________________________________
Cranial Nerve X _________________________________________________________
Cranial Nerve XI _________________________________________________________
Cranial Nerve XII ________________________________________________________
SKIN Color Moisture
Skin Integrity/Condition o Normal o Normal
o Intact o Pale o Dry
o Rash o Cyanotic o Diaphoretic
o Lesion o Flushed Mouth
o Ulcer o Mottled o Pink/Moist
o Bruising o Jaundiced o Ulcers
o Scars o Lesions
o Burns Temperature o Bleeding
Describe: _____________ o Warm
_____________________ o Hot Lips
_____________________ o Cool o Dry
IV Access o Cold o Cracked
o Peripheral o Intact
o Central Note: _______________ o Lesions
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HEAD
Hair Describe: ________________________________________
o Lice ________________________________________________
o Dandruff ________________________________________________
o Lesions ________________________________________________
o Bald ________________________________________________
Face ________________________________________________
o Acne
o Scars
o Wounds/Lesions
EYES: Vision EAR TEETH
o No Impairment Dentures
o R/L Impaired Hearing o Yes
o R/L Blind o No Impairment o No
o Glass/Contact o R/L Impairment
Caries
o Lenses o R/L Hearing Aide
o Yes
o Others
COLOR Describe: o No
o Clear ______________________ Brace
o Yellow ______________________ o Yes
o Red R/L ______________________ _________________ o No
o Drainage R/L
o N/A
CARDIOVASCULAR Brachial Pulse
Neck o Strong R/L
o Flat o Faint R/L
o Distended o Doppler R/L (If applicable)
Apical Pulse Pedal Pulse
o Strong R/L
o Regular
o Faint R/L
o Irregular o Doppler R/L (If Applicable)
o Pacemarker Type: _____________ Edema
Rate: _____________ o No
Heart Sound o Yes
o Normal Site: _____________________
o Abnormal Numbness
o No
Note: _______________________________
o Yes
____________________________________ Site: _______________________
Radial Pulse
o Strong R/L
o Faint R/L
o Doppler R/L (if Applicable)
Note: ______________________________
RESPIRATORY Tracheostomy
Retraction o Yes
o N/A o No
o Supraclavicular Date Inserted: ____________
o Intercostal Date Tube Change: ________
o Diaphragmatic
Cough Describe: Chest Tube
o N/A _________________ o Yes
o Non-productive _________________ o No
Ability to clear secretions Oxygen
o Yes o Room Air
o No o Nasal Cannula
Breath Sounds o Facemask
o Clear o Trach Mask
o Equal o Endotracheal Tube
o BIPAP
o CPAP
Gastrointestinal Constipation
Abdominal o Yes
o Soft o No
o Firm Diarrhea
o Rigid o Yes
o Distended o No
Tenderness Date of Last BM:
o N/A Appetite
o Yes o Good
Location: ______________ o Fair
Bowel Sounds o Poor
o Present _______sounds/min. o Nausea
o Absent o Vomiting
Feed Independently Chewing/Swallowing Difficulties
o Yes o Yes
o No o No
Nasogastric Tube/ Gastrostomy Tube Describe: _________________
o Yes __________________________
o No __________________________
NGT date change: ____________
EXTREMITIES
UPPER LOWER
Fingers Toes
o Complete __________________ o Complete _______________
o Arthritis __________________ o Arthritis _______________
o Callus __________________ o Callus _______________
Nails Nails
o Cyanotic o Cyanotic
o Club o Club
o Dirt o Dirt
o Cut o Cut
Arms Legs
o Lesions o Lesions
o Scars o Scars
o Arthritis o Arthritis
o Others ___________________ o Others __________________
___________________ __________________
___________________ __________________
Genital and Anal
Male Female
o Lice o Lice
o STI ____________________ o STI _______________
o Catheter o Catheter
o Hernia o Hernia
o Others ___________________ o Menstruation Date Start: __________
___________________ Date End: __________
Anus o Others _________________________
o Hemorrhoids Anus
o STI o Hemorrhoids
o STI _________________
Descriptive: Indicate all observed in the diagram (Male and Female)
Front Back
PATHOPHYSIOLOGY
Last Name First Name Middle Name
Reason for Hospitalization:
Admission Impression:
Diagnosis:
Prognosis:
Address: Age:
SCHEMATIC DIAGRAM
RISK FACTORS
Predisposing Precipitating
HEALTH TEACHING
Last Name First Name Middle Name
Reason for Hospitalization:
Admission Diagnosis:
Health Teachings in Relation to the Disease Process
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Health Teaching in Relation to Patient’s Medication
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Health Teaching in Relation to Patient’s Diet
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Health Teachings in Relation to Patient’s Exercise
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