Date of Interview: ___________________________
Informant: ____________________________
Rel. to px: ________________________________________________
Px name: __________________
Age/Bday:
Sex: [ ] F [ ] M
Address:
Civil status: [ ] Single [ ] Married [ ] Divorced [ ] ______________
Date/Time Admitted:
- ___ AM ___ PM
Chief complaint: ___________________________________________
Ward: ______________ Bed No.: ___________
Allergies: _________________________________________________
Religious affiliation: _________________________________________
Physician’s Initial:
___________________________________________
c.
Relevant Family History
_________________________________________________________
_________________________________________________________
_________________________________________________________
d.
Disability Assessment
_________________________________________________________
_________________________________________________________
_________________________________________________________
Past Health Problems/Status
a.
Childhood illnesses
[ ] _______________________________________________________
[ ] _______________________________________________________
[ ] _______________________________________________________
b.
Immunization
TYPE
DATE RECEIVED
A
History of Present Illness
a.
Usual Health Status
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
b.
Chronologic Story
Characteristic:
Onset:
Location:
Duration:
Severity:
Pattern:
Assoc. Factors:
f.
Name
Medications
Dose
B
C
c.
Allergies (and response, remedy)
[ ] ________________ [ ] ________________ [ ] ________________
_________________________________________________________
_________________________________________________________
d.
Accidents/Injuries
How:_____________________________________________________
When:___________________________________________________
Where:_____________________ Treatment: ____________________
Complications: _____________________________________ [ ] None
e.
Hospitalization for serious illnesses:
Date confine: _____________________ No. of days in hosp.:
________
Hospital: _____________________
Reason:______________________
Physician: ________________ Meds:
___________________________
d.
Drinking Patterns
Kind of Fluid
Amount
Freq
Time
Pattern
Reason
e.
Type
Family History of Illness
________________________________________________________
________________________________________________________
________________________________________________________
Patients Expectations
Hospital: ________________________________________________
Nursing Care: ____________________________________________
Patterns of Functioning
a.
Breathing Patterns
Respiratory problems:
Remedy:
Manner of Breathing:
b.
Circulation
Usual BP:
History:
c.
Sleep Pattern
Usual Bedtime:
No. of Pillows/Placement: ____________________________________
Bedtime Rituals: [ ] Toothbrush [ ] Skincare [ ] Meds [ ] Bath [ ] Others
_________________________________________________________
Problems: ________________________________________________
Remedy: _________________________________________________
Eating Patterns
Usual Food/Amount
Time
Food likes: _______________________________________________
Food dislikes: _____________________________________________
f.
Elimination Patterns
Bowel Frequency:
Problems/Difficulty:
Remedy:
Urine Frequency:
Problems:
Remedy:
g.
Exercise
h.
Hygiene
Bath Type:
Frequency:
Time:
Oral Frequency:
Care of Dentures:
Shaving Frequency:
Cosmetics:
i.
Recreation
j.
Health Supervision
General Appearance
1.
Compare client’s age with appearance
2.
Observe body build, height, weight in relation to client’s age, lifestyle, and
health
3.
Observe client facial expression, posture, position
4.
Observe overall hygiene and grooming and relate to prior activity
5.
Note body odor, breath odor and relate to prior activity
6.
Note signs of health or illness
7.
Assess client’s attitude, attentiveness, affect, and mood, and
appropriateness of responses
8.
Listen for quantity, quality, relevance, and organization of speech
Skin
1.
2.
3.
4.
5.
Inspect skin for color and uniformity
Skin moisture
Palpate skin temperature
Skin turgor, Edema
Skin lesions
Hair
1.
2.
3.
Inspect evenness of growth, hair thickness/thinness, texture, oiliness
Note presence of infection or infestations
Inspect body hair
Skull and Face
1.
Inspect skull for size, shape, symmetry
2.
Facial feature symmetry
3.
Note facial expressions and symmetry of facial movements (CN VII)
4.
Palpates the skull for nodules, masses, depressions
5.
Palpate temporal artery on both sides
6.
Palpate temporomandibular joints
7.
TMJ ROM
Mouth and Throat
1.
Inspect lips for color, texture, symmetry
2.
Using penlight, inspects:
a.
Inner and buccal mucosa
b.
Teeth for color, presence of fillings, dental caries, partial or
complete dentures, and tartar
c.
Gums (bleeding)
d.
Tongue
e.
Hard and soft palates
f.
Salivary gland openings - swelling and redness
g.
Palatine arches
h.
Tonsils
i.
Oropharynx
3.
Sense of taste (CN VII)
4.
Wears gloves and palpates lips, buccal mucosa, gums, tongue, and floor of
the mouth
5.
Observes uvula for position and mobility as the client phonates “ah”
6.
Tests gag reflex (CN IX and X)
7.
Motor activity of pharynx – Swallow (CN XII)
8.
Movement of tongue (CN XII)
Ears and Hearing
1.
Inspect auricles for color, texture, symmetry, position, size, angle
2.
Palpate auricles for texture, elasticity, tenderness. Move auricle and push
tragus for tenderness.
3.
Inspect external ear canal for cerumen, inflammation, scaling, drainage,
foreign bodies
4.
Test hearing acuity with whisper test (CN VIII)
5.
Watch Tick Test
6.
Hearing acuity with tuning fork. Weber and Rinne test
Nose and Sinuses
1.
Patency of both nasal cavities
2.
Test sense of smell (CN I)
3.
Using speculum, or penlight
a.
Mucosa
b.
Nasal septum
4.
Palpate external nose
5.
Palpate sinuses – maxillary and frontal
6.
Transilluminate – maxillary and frontal
Posterior Chest
1.
Respiratory rate
2.
Respirations excursion, depth, rhythm, and pattern
3.
Skin color, chest configuration, chest symmetry
4.
Inspect and palpate scapula and spine
5.
Palpates
a.
Expansion
b.
Tactile fremitus
6.
Percuss over all lung fields
7.
Percuss for diaphragmatic excursion
8.
Auscultates
a.
Adventitious sounds
b.
Ninety-nine
c.
Ee-ee-ee-ee
d.
A-b-c
Anterior Chest
1.
Respirations for excursion, depth, rhythm, and pattern
2.
Skin color and chest configuration
3.
Palpates
a.
Expansion
b.
Tactile fremitus
4.
Percuss lung fields
5.
Auscultates adventitious sounds
Inguinal Region
1.
Palpate – Inguinal lymph nodes and to detect any hernias and
femoral pulses
Abdomen
1.
Inspects skin integrity, contour, symmetry, location of umbilicus
2.
Observe movement of respiration, peristalsis, or aortic pulsations
3.
Auscultates – bowel sounds, vascular sounds
4.
Percuss – tympany and dull, liver, spleen
5.
Palpate – light, deep, blumberg, rovsing, psoas, liver, spleen
6.
Murphy’s sign
7.
Abdominal reflex
Heart
1.
Inspects and palpates – pulsations, lifts, heaves
a.
Aortic
b.
Pulmonic
c.
Tricuspid
d.
Apical
2.
Auscultate
a.
Aortic
b.
Pulmonic
c.
Tricuspid
d.
Apical
3.
Auscultate and counts heart 1 full minute
Breasts and Axillae
1.
Inspect breast – symmetry, mobility, masses, dimpling, and nipple
retraction (Lift arms over head, press hands on hips, lean forward)
2.
Palpate nipples, axillary, subclavicular, supraclavicular lymph nodes
and support client arm
3.
Lift arms and palpate each breast
4.
Teach BSE
Nails
1.
Inspect nail – curvature, angle, texture, color, tissue surrounding
2.
Blanch test for capillary refill
Upper Extremities
1.
Symmetry
a.
Both shoulders, lateral and medial aspect of elbow
and wrist, dorsum of hands and palms
2.
Palpates both
a.
Brachial and Radial pulses
b.
Epitrochlear nodes
3.
Allen test – open close hands and pinch artery
4.
Palpates
a.
Shoulders, later and medial aspect of olecranon
process, wrist and hand joints, temperature and
texture of hands
5.
ROM and muscle strength
Neck
1.
Inspect neck – symmetry, pulsations, swellings, masses
2.
Inspect jugular veins – pulsations and distention
3.
ROM neck
4.
Muscle strength of neck (CN XI) – head to side and shrug
5.
Palpates
a.
Lymph nodes
b.
Carotid pulse
c.
Trachea position
d.
Thyroid gland
Eyes and Vision
1.
Inspect eyebrows, eyelashes, and eyelids, bulbar, and palpebral
conjunctivae (color, texture, lesions)
2.
Lacrimal apparatus edema or redness
3.
Cornea clarity and texture
4.
Anterior chamber for transparency and depth
5.
Pupil color, size, shape, and equality
6.
Test visual acuity with Snellen’s (CN II)
7.
Test peripheral visual fields (confrontation)
8.
Cover test
9.
6 cardinal fields of gaze (CN III, IV, VI)
10.
Pupillary reaction to light (CN III)
11.
Accommodation of pupil response
12.
Corneal reflex (Hirschberg Test) (CN V, VII)
Upper Extremities
1.
Symmetry
a.
2.
3.
4.
5.
Both shoulders, lateral and medial aspect of elbow and wrist,
dorsum of hands and palms
Palpates both
a.
Brachial and Radial pulses
b.
Epitrochlear nodes
Allen test – open close hands and pinch artery
Palpates
a.
Shoulders, later and medial aspect of olecranon process, wrist
and hand joints, temperature and texture of hands
ROM and muscle strength
Nails
1.
Inspect nail – curvature, angle, texture, color, tissue surrounding
2.
Blanch test for capillary refill
Breasts and Axillae
1.
Inspect breast – symmetry, mobility, masses, dimpling, and nipple retraction
(Lift arms over head, press hands on hips, lean forward)
2.
Palpate nipples, axillary, subclavicular, supraclavicular lymph nodes and
support client arm
3.
Lift arms and palpate each breast
4.
Teach BSE
Abdomen
1.
Inspects skin integrity, contour, symmetry, location of umbilicus
2.
Observe movement of respiration, peristalsis, or aortic pulsations
3.
Auscultates – bowel sounds, vascular sounds
4.
Percuss – tympany and dull, liver, spleen
5.
Palpate – light, deep, blumberg, rovsing, psoas, liver, spleen
6.
Murphy’s sign
7.
Abdominal reflex
Inguinal Region
1.
Palpate – Inguinal lymph nodes and to detect any hernias and femoral
pulses