P. O. N. R.

COMPREHENSIVE NURSING HEALTH HISTORY AND PHYSICAL EXAMINATION

Note: Fill-up and check the corresponding boxes and circles below.
I.

NURSING HEALTH HISTORY

A. Biographic Data/Identifying Data

Name of Patient:
Age:
Sex:
Date of Birth:
Place of Birth:
Home Address:
Religion:
Nationality:
Civil Status:
Occupation:
Educational Attainment:
Blood Type:
Height:
Weight:
B. Admission Data
Name of Hospital:
Hospital Case Number:
Admission Case Number:
Room:
Date of Admission:
Time of Admission:
Mode of Admission:
Admitting Vital Signs
Temperature:
Heart Rate:
Respiratory Rate:
Blood Pressure:
Date and Time of Clinical Encounter:
Admitting Physician:
Attending Physician:
Chief Complaint (CC) or Reason for Seeking Medical Care:
Admitting Impression:
Admitting Diagnosis:
Final Diagnosis:
Health Care Financing and Usual Source of Medical Care:
Source and Reliability of Data Gathered:
C. History of Present Illness (HPI)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
D. Past Health History (include the date, course of recovery & complications if any)
a. Childhood Illnesses
Chicken Pox at age_____
Mumps at age_____
Measles at age_____
Rubella (German measles) at age_____
Poliomyelitis at age_____
Pertusis at age_____

 Scarlet fever at age_____

Smallpox at age_____
Chicken pox at age_____
Rheumatic fever at age_____
Others (specify) _____
b. Childhood Immunizations (include the age and date it was given)
BCG_____
DPT_____
OPV_____
Hepatitis A_____
Hepatitis B_____
Influenza_____
MMR_____
Others (specify) _____
c. History of Hospitalizations (include the date, course of recovery & complications, if any)
Medical History
No major problems
Tuberculosis_____
Coronary Artery Disease_____
Hypertension_____
Dyslipedemia_____
Cancer_____
Autoimmune disorders (specify) _____
Hepatitis (specify) _____
Obesity_____
Diabetes Mellitus (specify type) _____
Glaucoma_____
Stroke_____
Arthritis (specify) _____
Gastric ulcer_____
Pneumonia_____
Others (specify) _____
Surgical History (include the date, course of recovery & complications, if any)
________________________________________________________________________
________________________________________________________________________
Accidents and Injuries (include the date, course of recovery & complications, if any)
________________________________________________________________________
________________________________________________________________________
d. Obstetric History
Age at menarche_____
Age at menopause_____
LMP_____
Regularity: Regular_____ or Irregular_____
Duration_____
Amount_____
Color_____
Number of pads per day_____
Dysmenorrheal and relieving measures_____
Menorrhagia and relieving measures_____
Metorrhagia and relieving measure_____
Pregnancy (specify) _____
Miscarriage/abortion (specify type and date) _____
Use of birth control methods (specify) _____
Patients view about sex_____
Satisfaction in their sex life_____
STDs_____
Screening tests (include the date and result)

Pap smears_____
Other tests done (specify) _____

e. Allergies and the type of reaction

___________________________________________________________________________
___________________________________________________________________________
f.

Medications (include name, dosage, frequency of all current and recent past medications and
date and time of last dose)
Vitamins, dietary aids and supplements (specify)_____
Laxatives_____
Aspirin_____
Acetaminophen_____
Antacids_____
Prescription drugs
____________________________________________________________________
____________________________________________________________________
Non-prescription drugs
____________________________________________________________________
____________________________________________________________________

E. Family Health History

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
F. Personal and Social Health History
Lifestyle
a. Personal habits (amount, frequency, duration of substance use: tobacco, coffee, cola, tea,
illicit or recreational drugs)
Tobacco (frequency, amount, duration, pack years)
____________________________________________________________________
____________________________________________________________________
Alcohol, drugs and related substances (frequency, amount, duration)
____________________________________________________________________
____________________________________________________________________
b. Diet

Typical diet on a normal day_________________________________________

Food and fluid intake___________________________________________________
Special diet (if any)____________________________________________________
Number of meals and snacks per day_______________________________________
Food allergies_________________________________________________________

c. Sleep/rest patterns
Usual sleep/wake up times_______________________________________________
Difficulties sleeping____________________________________________________
Remedies used for difficulty of sleeping____________________________________
Relaxation pattern______________________________________________________
d. Elimination patterns
Patterns of excretory function
o Bladder: Frequency of urination per day_____
Difficulties of urination_____
o Bowel: Frequency of defecation per day_____
Difficulties of defecation_____
o Skin: Presence of excessive sweating (specify location) _____

e. Activities of Daily Living (ADL)

Difficulties experienced in the basic activities of eating, grooming, dressing,
elimination, and/or locomotion
____________________________________________________________________
f.

Instrumental activities of daily living

Difficulties experienced in food preparation, shopping, transportation, housekeeping,
laundry, and ability to use the telephone, handle finances, and manage medications
____________________________________________________________________

g. Recreation/Hobbies
Exercise activity and tolerance
____________________________________________________________________
Hobbies and other interests
____________________________________________________________________
Vacations and/or leisure activities
____________________________________________________________________
Social Data
a. Family relationships/friendships
Support system in times of stress, effect of clients illness on the family, family
problems affecting the client
____________________________________________________________________
____________________________________________________________________
b. Ethnic affiliation
Health customs and beliefs, cultural practices that may affect health care and
recovery
____________________________________________________________________
____________________________________________________________________
c. Educational history
Clients highest level of education attained and any past difficulties in learning
____________________________________________________________________
____________________________________________________________________
d. Occupational history
Current employment status, number of days missed from work because of illness, any
history of accidents on the job, occupational hazards with a potential future disease or
accident, clients need to change because of past illness, employment status of
spouses or partner, clients overall satisfaction with the work
____________________________________________________________________
____________________________________________________________________
e. Economic status
Information about how the client is paying for medical care (including what kind of
medical and hospitalization coverage the client has), whether clients illness presents
financial concerns
____________________________________________________________________
____________________________________________________________________
f.

Home and neighborhood conditions

Home safety measures and adjustments in physical facilities that may be required to
help client manage a physical disability, activity intolerance, and ADLs; the
availability of neighborhood community services to meet the clients needs; or
conditions that may have contributory to the development disease/condition
____________________________________________________________________
____________________________________________________________________

G. Psychological Data
a. Major stressors experienced and clients perception of them
___________________________________________________________________________
___________________________________________________________________________
b. Usual coping pattern
___________________________________________________________________________
___________________________________________________________________________
c. Self-perception/self-concept pattern
___________________________________________________________________________
___________________________________________________________________________
d. Self-concept, worth, comfort, body image, feeling state
___________________________________________________________________________
___________________________________________________________________________
e. Communication style
___________________________________________________________________________
___________________________________________________________________________
f.

Ability to verbalize appropriate emotion; non-verbal communication such as eye

movements, gestures use of touch, posture, interactions with support; and congruence of nonverbal behavior and verbal expression
___________________________________________________________________________
___________________________________________________________________________

H. Patterns of Health Care

a. Health care resources currently used and used in the past
___________________________________________________________________________
___________________________________________________________________________
b. Caregivers (physicians, specialist, dentists, folk practitioners, health clinic, and health center
visits)
___________________________________________________________________________
___________________________________________________________________________
c. View of the client about adequacy of care being provided and whether access to health care is
a problem
___________________________________________________________________________
___________________________________________________________________________

II.

REVIEW OF SYSTEM (ROS)

A. General
Usual weight_____ Recent weight change_____
Weakness
Fatigue
Fever
Other pertinent data_________________________________________________________________
B. Integumentary System (Skin, Hair and Nails) (include type, location, causation, length of time the
problem existed, treatments, recurrences, and other pertinent data). The patient had history of:
Itching_____
Lesion_____
Abrasion_____
Pigmented spots_____
Bruises_____
Tendency to bruise easily_____
Use of medications, lotions, home remedies (specify) _____
History of jaundice_____
Excessively dry skin_____
Excessively moist skin_____
Rashes_____
Abnormal changes in hair_____
Previous skin infections (specify) _____
Recent use of hair dyes, curling/straightening preparations_____
Recent chemotherapy (if alopecia is present) (specify type) _____
Other pertinent data_____
C. Head, Eyes, Ears, Nose, and Throat (HEENT)
a. Head (include type, location, causation, length of time the problem existed, treatments,
recurrences and other pertinent data). The patient had history of:
Problems with lumps/bumps (specify) _____
Itching_____
Scaling or dandruff_____
Loss of consciousness_____
Dizziness_____
Lightheadedness_____
Seizure_____
Headache_____
Facial pain_____
Head injury_____
Other pertinent data_____
b. Eyes and Vision (include type, location, causation, length of time the problem existed,
treatments, recurrences and other pertinent data). The patient had history of:
Eye injury_____
Eye surgery_____
Eye problem_____
Use of contact lens/eye glasses (specify grade)_____
Changes in visual acuity_____
Blurred vision_____
Tearing_____
Photophobia_____
Itching_____
Pain_____
Glaucoma_____
Cataracts_____
Double vision_____
Last visit to an ophthalmologist_____
Current use of eye medication (specify) _____
Other pertinent data_____

c. Ears and Hearing (include onset, factors contributing to it, causation, length of time the
problem existed, treatments, recurrences, how it interferes with ADL and other pertinent
data). The patient had history of:
Hearing problems_____
Ringing in the ears (tinnitus) _____
Earaches_____
Infections_____
Discharges_____
Use of corrective hearing device (specify when and from whom it was obtained) _____
Other pertinent data_____
d. Nose and Sinuses (include type, location, causation, length of time the problem existed,
treatments, recurrences and other pertinent data). The patient had history of:
Allergies_____
Frequent colds_____
Nasal stuffiness_____
Sinus infection_____
Injuries to the nose/face_____
Nosebleeds_____
Changes in sense of smell_____
Other pertinent data_____
e. Oropharynx (Mouth and Throat) (include type, location, causation, length of time the
problem existed, treatments, recurrences and other pertinent data). The patient had history of:
Mouth ulcers and other lesions_____
Tumors_____
Bleeding gums_____
Sore tongue_____
Dry mouth_____
Frequent sore throat_____
Hoarseness_____
Last visit to a dentist_____
Routine pattern of dental care_____
Dentures (specify type and how it fits) _____
Other pertinent data_____
D. Neck (include type, location, causation, length of time the problem existed, treatments, recurrences
and other pertinent data). The patient had history of:
Neck lumps_____
Neck pain_____
Stiffness_____
Goiter_____
Previous diagnosis with thyroid problems (specify date when the patient was
diagnosed)_____
Other pertinent data_____
E. Breasts and Axillae (include type, location, causation, length of time the problem existed,
treatments, recurrences and other pertinent data). The patient had history of:
Performance of breast self-examination (specify technique used, and when performed in
relation to menstrual cycle)_____
Presence of breast masses (specify location, diameter and others) _____
Pain in the breast (specify in relation to the menstrual cycle and others) _____
Other pertinent data_____
F. Thorax and Lungs (include type, location, causation, length of time the problem existed, treatments,
recurrences and other pertinent data). The patient had history of:
Cough (specify if productive/non-productive) _____
Sputum (specify color, quantity) _____
Hemoptysis _____
Dyspnea _____
Pleurisy _____
Bronchitis _____

Emphysema _____
Pneumonia _____
Asthma _____
Wheezing _____
Chest pain on respiration_____
Lung cancer_____
Allergies _____
Tuberculosis _____
Being a smoker_____
Being exposed to occupational hazards_____
Date of last chest x-ray and result_____
Other pertinent data_____

G. Cardiovascular System and Peripheral Vascular System (include type, location, causation, length
of time the problem existed, treatments, recurrences and other pertinent data). The patient had history
of:
Rheumatic fever_____
Heart murmurs_____
Heart attack/heart failure_____
Varicosities _____
Arterial disease_____
Intermittent claudication_____
Past clots in veins_____
Hypertension (specify BP) _____
Past electrocardiographic or other heart tests and results_____
Presence of symptoms indicative of heart disease_____
o Fatigue _____
o Dyspnea _____
o Orthopnea _____
o Edema _____
o Chest pain_____
o Palpitations _____
o Syncope _____
Presence of diseases that affect the heart_____
o Obesity _____
o Diabetes (specify type) _____
o Lung disease_____
o Endocrine disorders (specify) _____
Lifestyle habits that are risk factors for cardiac disease_____
o Smoking _____
o Alcohol intake_____
o Poor exercise habits_____
o Exercise intolerance_____
Other pertinent data_____
H. Gastrointestinal System (include type, location, causation, length of time the problem existed,
treatments, recurrences and other pertinent data). The patient had history of:
Abdominal pain_____
Onset
o Sudden
o Gradual
Location_____
Sequence and Chronology of the abdominal pain_____
Quality/description of the abdominal pain_____
Frequency_____
Associated symptoms_____
Changes in appetite (specify)_____
Food intolerance_____
Food ingested in the last 24 hours_____
Heart burn_____
Flatulence _____
Excessive belching_____

Difficulty swallowing (dysphagia) _____

Nausea _____
Vomiting _____
Hematemesis (vomiting of blood) _____
Fecal incontinence_____
Gastric ulcer_____
Gallbladder problems_____
Liver problems_____
Bowel habits (specify) _____
Incidence of constipation (specify color and size) _____
Incidence of diarrhea (specify color and amount) _____
Blood in stool (specify whether melena/hematochezia) _____
Hemorrhoids _____
Mucus in stools_____
Excessive passing of gas_____
Other pertinent data_____

I. Musculoskeletal System (include type, location, causation, length of time the problem existed,
treatments, recurrences and other pertinent data). The patient had history of:
Muscle joint/pain_____
Onset
o Sudden
o Gradual
Location_____
Manifestations_____
o Redness
o Swelling
o Stiffness
o Weakness
o Limitations to movement
Aggravating factors_____
Alleviating factors_____
Inability to perform ADL_____
Previous sports injuries/trauma (specify) _____
Loss of functions without pain (specify) _____
Arthritis _____
Gout _____
Backache _____
Other pertinent data_____
J. Neurologic System (include type, location, causation, alleviating and aggravating factors, treatments,
recurrences and other pertinent data). The patient had history of:
Presence of pain in the head, back, or extremities (specify) _____
Disorientation to time, place, or person (specify) _____
Speech disorder_____
Loss of consciousness_____
Fainting_____
Blackouts _____
Convulsions _____
Trauma _____
Tingling/pins and needles sensations (specify) _____
Numbness (loss of sensation) _____
Limping _____
Paralysis _____
Tremors or tics_____
Uncontrolled muscle movement_____
Loss of memory_____
Mood swings_____
Problems with smell, vision, taste, touch or hearing (specify) _____
Other pertinent data_____

K. Urinary System (include type, location, causation, alleviating and aggravating factors, treatments,
recurrences and other pertinent data). The patient had history of:
Frequency of urination per day_____
Frequency of urination at night_____
Anuria _____
Polyuria _____
Nocturia _____
Urgency _____
Burning or painful urination_____
Urinary incontinence_____
Hematuria _____
Urinary infections_____
Kidney stones_____
Date and time last voided (color, frequency, amount, and transparency) _____
Reduced caliber or force of urinary stream_____
Hesitancy _____
Dribbling _____
Other pertinent data_____
L. Reproductive System (include type, location, causation, alleviating and aggravating factors,
treatments, recurrences and other pertinent data). The patient had history of:
In Males
Hernia _____
Penile discharge_____
Sores on the penis_____
Testicular pain_____
Testicular mass_____
Dyspareunia _____
History of STD and treatments (if any) _____
Sexual habits, interest, function, satisfaction_____
Contraceptives used_____
Other pertinent data_____
In Females
Vaginal discharge_____
Itching _____
Sores _____
Lumps _____
Dyspareunia _____
History of STD and treatments (if any) _____
Other pertinent data_____
M. Hematologic (include type, location, causation, alleviating and aggravating factors, treatments,
recurrences and other pertinent data). The patient had history of:
Anemia _____
Easy bruising_____
Easy bleeding_____
Past transfusions_____
Transfusion reactions (if any) _____
Other pertinent data_____
N. Endocrine System (include type, location, causation, alleviating and aggravating factors, treatments,
recurrences and other pertinent data). The patient had history of:
Thyroid trouble_____
Heat intolerance_____
Cold intolerance_____
Excessive sweating_____
Excessive thirst_____
Excessive hunger_____
Polyuria _____
Other pertinent data_____

10

O. Psychiatric (include type, location, causation, alleviating and aggravating factors, treatments,
recurrences and other pertinent data). The patient had history of:
Nervousness _____
Tension _____
Mood _____
Depression _____
Memory changes_____
Suicide attempt (if relevant) _____
Use of psychiatric drugs (specify) _____
Other pertinent data_____

11

III.

PHYSICAL ASSESSMENT

A. General Survey
_________________________________________________________________________________
_________________________________________________________________________________
B. Integumentary System
a. Skin
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
b. Hair
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
c. Nails
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
C. Head, Eyes, Ears, Nose and Throat (HEENT)
a. Skull and Face
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
b. Eyes and Vision
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
c. Ears and Hearing
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
d. Nose and Sinuses
Inspection
______________________________________________________________
______________________________________________________________

12

Palpation
______________________________________________________________
______________________________________________________________
e. Oropharynx (Mouth and Throat)
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
D. Neck
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
E. Thorax and Lungs
a. Posterior
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
Percussion
______________________________________________________________
______________________________________________________________
Auscultation
______________________________________________________________
______________________________________________________________
b. Anterior
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
Percussion
______________________________________________________________
______________________________________________________________
Auscultation
______________________________________________________________
______________________________________________________________
F. Cardiovascular System and Peripheral Vascular System
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
Percussion
______________________________________________________________
______________________________________________________________
Auscultation
______________________________________________________________
______________________________________________________________

13

G. Breasts and Axillae

Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
H. Abdomen
Inspection
______________________________________________________________
______________________________________________________________
Auscultation
______________________________________________________________
______________________________________________________________
Percussion
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
I. Musculoskeletal System
a. Upper Extremities
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
b. Lower Extremities
Inspection
______________________________________________________________
______________________________________________________________
Palpation
______________________________________________________________
______________________________________________________________
J. Neurologic System
Mental status_____
Aphasia_____
Oriented to_____
o Time _____
o Person _____
o Place _____
Good memory (as evidenced by) _____
Attention span (specify) _____
Calculation skills (specify) _____
Level of consciousness_____
Glasgow Coma Scale (GCS) score_____
Cranial nerves (specify) _____
Reflexes (use the scale in grading reflexes) _____
Motor function (specify the grade of muscle strength) _____
Sensory function_____
Other pertinent findings_____
K. Reproductive System
Inspection and Palpation
______________________________________________________________
______________________________________________________________

14

IV.

PATIENT CLINICAL APPRAISAL

DAY 1
A. Health Perception/Health Management Pattern (describes the clients perceived pattern of
health and well being and how health is managed)
___________________________________________________________________________
___________________________________________________________________________
B. Nutritional/Metabolic Pattern (describes the clients pattern of food and fluid consumption
relative to metabolic need and pattern indicators of nutrient supply)
a. Typical Intake (Food/Fluid)
______________________________________________________________
______________________________________________________________
b. Diet
______________________________________________________________
______________________________________________________________
c. Diet Restriction
______________________________________________________________
______________________________________________________________
d. Weight
______________________________________________________________
______________________________________________________________
e. Medication/Food Supplement
______________________________________________________________
______________________________________________________________
C. Elimination Pattern (describes the patterns of excretory function bowel, bladder and skin)
a. Urine
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Transparency:_________________________________________________
b. Bowel Movement
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Consistency:___________________________________________________
D. Activity Exercise Pattern (describes the pattern of exercise, activity, leisure and recreation)
___________________________________________________________________________
___________________________________________________________________________
E. Sleep/Rest Pattern (describes patterns of sleep, rest and relaxation)
a. Activities
______________________________________________________________
b. Rest
______________________________________________________________
c. Sleeping Pattern
______________________________________________________________
F. Cognitive/Perceptual Pattern (describes sensory perceptual and cognitive patterns)
a. Mental Status
______________________________________________________________

15

b. Condition of Five (5) Senses

______________________________________________________________
G. Self-Perception/Self-Concept Pattern (describes the clients self-concept pattern and
perception of self e.g. self-perception/worth, comfort, body image, feeling state)
a. Perception of Self
______________________________________________________________
b. Support System
______________________________________________________________
c. Mood/Affect
______________________________________________________________
H. Role/Relationship Pattern (describes the clients pattern of role participation and
relationships)
___________________________________________________________________________
___________________________________________________________________________
I. Sexuality/Reproductive Pattern (describes clients pattern of satisfaction, and
dissatisfaction with sexuality pattern; describes reproductive pattern)
___________________________________________________________________________
___________________________________________________________________________
J. Coping/Stress Tolerance Pattern (describes the clients general coping pattern and the
effectiveness of the pattern in terms of stress tolerance)
a. Coping Mechanism
______________________________________________________________
K. Value/Belief Pattern (describes the patterns of values, beliefs including spiritual, and goals
that guide the clients choices or decisions)
___________________________________________________________________________
___________________________________________________________________________
L. Oxygenation and Vital Signs
a. Temperature:_____
b. Heart Rate:_____
c. Respiratory Rate:_____
d. Blood Pressure:_____
e. Lung Sounds:_____
f. Respiratory Problems:_____
M. Pain
a.
b.
c.
d.
e.
f.
g.

Onset:_____
Location:_____
Duration:_____
Intensity:_____
Associated Manifestations:_____
Alleviation/Aggravation:_____
Medications
______________________________________________________________
______________________________________________________________

16

DAY 2
A. Health Perception/Health Management Pattern (describes the clients perceived pattern of
health and well being and how health is managed)
___________________________________________________________________________
___________________________________________________________________________
B. Nutritional/Metabolic Pattern (describes the clients pattern of food and fluid consumption
relative to metabolic need and pattern indicators of nutrient supply)
a. Typical Intake (Food/Fluid)
______________________________________________________________
______________________________________________________________
b. Diet
______________________________________________________________
______________________________________________________________
c. Diet Restriction
______________________________________________________________
______________________________________________________________
d. Weight
______________________________________________________________
______________________________________________________________
e. Medication/Food Supplement
______________________________________________________________
______________________________________________________________
C. Elimination Pattern (describes the patterns of excretory function bowel, bladder and skin)
a. Urine
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Transparency:_________________________________________________
b. Bowel Movement
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Consistency:___________________________________________________
D. Activity Exercise Pattern (describes the pattern of exercise, activity, leisure and recreation)
___________________________________________________________________________
___________________________________________________________________________
E. Sleep/Rest Pattern (describes patterns of sleep, rest and relaxation)
a. Activities
______________________________________________________________
b. Rest
______________________________________________________________
c. Sleeping Pattern
______________________________________________________________
F. Cognitive/Perceptual Pattern (describes sensory perceptual and cognitive patterns)
a. Mental Status
______________________________________________________________
b. Condition of Five (5) Senses
______________________________________________________________

17

G. Self-Perception/Self-Concept Pattern (describes the clients self-concept pattern and

perception of self e.g. self-perception/worth, comfort, body image, feeling state)
a. Perception of Self
______________________________________________________________
b. Support System
______________________________________________________________
c. Mood/Affect
______________________________________________________________
H. Role/Relationship Pattern (describes the clients pattern of role participation and
relationships)
___________________________________________________________________________
___________________________________________________________________________
I. Sexuality/Reproductive Pattern (describes clients pattern of satisfaction, and
dissatisfaction with sexuality pattern; describes reproductive pattern)
___________________________________________________________________________
___________________________________________________________________________
J. Coping/Stress Tolerance Pattern (describes the clients general coping pattern and the
effectiveness of the pattern in terms of stress tolerance)
a. Coping Mechanism
______________________________________________________________
K. Value/Belief Pattern (describes the patterns of values, beliefs including spiritual, and goals
that guide the clients choices or decisions)
___________________________________________________________________________
___________________________________________________________________________
L. Oxygenation and Vital Signs
a. Temperature:_____
b. Heart Rate:_____
c. Respiratory Rate:_____
d. Blood Pressure:_____
e. Lung Sounds:_____
f. Respiratory Problems:_____
M. Pain
a.
b.
c.
d.
e.
f.
g.

Onset:_____
Location:_____
Duration:_____
Intensity:_____
Associated Manifestations:_____
Alleviation/Aggravation:_____
Medications
______________________________________________________________
______________________________________________________________

18

DAY 3
A. Health Perception/Health Management Pattern (describes the clients perceived pattern of
health and well being and how health is managed)
___________________________________________________________________________
___________________________________________________________________________
B. Nutritional/Metabolic Pattern (describes the clients pattern of food and fluid consumption
relative to metabolic need and pattern indicators of nutrient supply)
a. Typical Intake (Food/Fluid)
______________________________________________________________
______________________________________________________________
b. Diet
______________________________________________________________
______________________________________________________________
c. Diet Restriction
______________________________________________________________
______________________________________________________________
d. Weight
______________________________________________________________
______________________________________________________________
e. Medication/Food Supplement
______________________________________________________________
______________________________________________________________
C. Elimination Pattern (describes the patterns of excretory function bowel, bladder and skin)
a. Urine
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Transparency:_________________________________________________
b. Bowel Movement
Color:________________________________________________________
Frequency:____________________________________________________
Amount:______________________________________________________
Consistency:___________________________________________________
D. Activity Exercise Pattern (describes the pattern of exercise, activity, leisure and recreation)
___________________________________________________________________________
___________________________________________________________________________
E. Sleep/Rest Pattern (describes patterns of sleep, rest and relaxation)
a. Activities
______________________________________________________________
b. Rest
______________________________________________________________
c. Sleeping Pattern
______________________________________________________________
F. Cognitive/Perceptual Pattern (describes sensory perceptual and cognitive patterns)
a. Mental Status
______________________________________________________________
b. Condition of Five (5) Senses
______________________________________________________________

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G. Self-Perception/Self-Concept Pattern (describes the clients self-concept pattern and

perception of self e.g. self-perception/worth, comfort, body image, feeling state)
a. Perception of Self
______________________________________________________________
b. Support System
______________________________________________________________
c. Mood/Affect
______________________________________________________________
H. Role/Relationship Pattern (describes the clients pattern of role participation and
relationships)
___________________________________________________________________________
___________________________________________________________________________
I. Sexuality/Reproductive Pattern (describes clients pattern of satisfaction, and
dissatisfaction with sexuality pattern; describes reproductive pattern)
___________________________________________________________________________
___________________________________________________________________________
J. Coping/Stress Tolerance Pattern (describes the clients general coping pattern and the
effectiveness of the pattern in terms of stress tolerance)
a. Coping Mechanism
______________________________________________________________
K. Value/Belief Pattern (describes the patterns of values, beliefs including spiritual, and goals
that guide the clients choices or decisions)
___________________________________________________________________________
___________________________________________________________________________
L. Oxygenation and Vital Signs
a. Temperature:_____
b. Heart Rate:_____
c. Respiratory Rate:_____
d. Blood Pressure:_____
e. Lung Sounds:_____
f. Respiratory Problems:_____
M. Pain
a.
b.
c.
d.
e.
f.
g.

Onset:_____
Location:_____
Duration:_____
Intensity:_____
Associated Manifestations:_____
Alleviation/Aggravation:_____
Medications
______________________________________________________________
______________________________________________________________

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V.

DISCHARGE PLAN (M.E.T.H.O.D.S.)

Name of Patient:
Nature: ____Home per request or ____Against medical advice
Final Diagnosis:
Date of Discharge:
Condition Upon Discharge:

A. Medications
_________________________________________________________________________________
_________________________________________________________________________________
B. Environmental Concerns
_________________________________________________________________________________
_________________________________________________________________________________
C. Treatments
_________________________________________________________________________________
_________________________________________________________________________________
D. Health Teachings
_________________________________________________________________________________
_________________________________________________________________________________
E. Out-Patient (Follow-up Check-up)
_________________________________________________________________________________
_________________________________________________________________________________
F. Diet
_________________________________________________________________________________
_________________________________________________________________________________
G. Spiritual
_________________________________________________________________________________
_________________________________________________________________________________

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