Nursing Related Learning Experience Manual

Name of Student Yr & Sec

Clinical Instructor Area
Date of Exposure Hospital

PATIENT HEALTH HISTORY

DATA BASE AND HISTORY

Name of Patient Civil Status Age

Address Nationality Sex
Religion Date of
Admission
Date of Birth Time of
Admission
Attending Consultant
Physician

T: _________0C PR: _________ bpm RR: ___________cpm BP:_________mmHg

( ) oral ( ) radial ( ) abdominal ( ) site: ______________
( ) rectal ( ) apical ( ) diaphragmatic ( ) position: ___________
Initial Vital Signs ( ) axillary ( ) regular
( ) tympanic ( ) irregular
( ) others, __________

Height: _______________ Weight: ________________

Chief Complaints

History of Present
Illness

History of Past
Illness

Family Health
History

( ) Yes If YES, list

Has received blood
dates
in the past?
( ) No

Blood reactions, if
any?

( ) Yes If YES, please

Allergies? specify
( ) No

Admitting Diagnosis

HEALTH ASSESSMENT

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

A. DIGESTIVE/METABOLIC/NUTRITION
Note: Assess for bowel habits, swallowing, bowel sounds, and comfort.

Objective Subjective

General Appearance: Usual Diet: ____________________________

□ Alert/responsive □ Apathetic _____________________________
□ Cachexia □ Abdominal Distention No. of meals per day: ___________
□ Mass □ Tenderness/pain No. of fluid drink each day: _______
Skin:
□ Dry □ Warm □ Cold □ Moist □ Edema □ Alcohol and Beverages________________

Turgor: ________________________________ Undesired Weight loss: □ Yes □ No

Undesired Weight gain: □ Yes □ No
Eyeball: □ Sunken □ Moist □Dry
Food restrictions R/T intolerance and health
Mouth: □ Dentures □ Braces □ Lesions problems or religious practices?
□ Cleft Palate □ Cleft Lip □ Ulcers ______________________________________
______________________________________
No. of teeth: ______________________ ______________________________________

Tongue: □ Dry □ Moist □ Furrows Difficulty in eating and swallowing:

______________________________________
Venous filling: ________ (Normal less than 3-5 ______________________________________
sec) ______________________________________

Intravenous Fluid: _______________________ Previous/Recent Illness:

Date of insertion: ________________________ □ Diabetic □ Hyperthyroidism □
Wounds:_______________________________ Hypothyroidism □ Colon Cancer □
Tube/Drainage: __________________________ Abdominal Pain
Comment:
Vital Signs: T ____ P ____ R_____ BP _____ ______________________________________
______________________________________
Body Types: ______________________________________
□ Ectomorph □ Mesomorph □ Endomorph ______________________________________
□ Obese □ Thin
Elimination pattern:
Loss of Appetite: □ Anorexia □ Bulimia □ Diarrhea □ Constipation
Body weight: _____________kg Frequency of BM:______________/day

Remarks

Nursing Diagnosis

B. RESPIRATORY SYSTEM

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Note: Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort

Objective Subjective
Breath Sounds: Previous/Recent Illnesses:
□ Diminished/Absent □ Stridor □ Bronchitis □ Emphysema
□ Rales/Crackles □ Rhonchi/Wheezing □ Asthma □ Brochiectasis
□ Normal (Vesicular, Bronchovesicular, Bronchial) □ Pneumonia □ Hydrothorax
□ None (atelectasis) □ Pneumothorax □ Hemothorax
□ CHF □ Chest Trauma
Resonance: □ Hyper □ Hypo □ Lung Cancer
Comment:
Respiration/Oxygenation: ______________________________________
□ Normal(Relax, Effortless and Quiet) ______________________________________
□ Labored/Use accessory Muscle] ______________________________________
□ Dyspnea ______________________________________
□ Tachypnea ______________________________________
□ Bradypnea ______________________________________
□ Cyanosis ______________________________________
□ Pallor
□ Cheyne-stoke Breathing Treatments/Medication:
□ Biot’s ______________________________________
□ Hyperventilation ______________________________________
□ Hypoventilation ______________________________________
□ Nasal Flaring ______________________________________
□ Pursed lip ______________________________________
□ Barrel Chest ______________________________________
□ Pleuritic Pain ______________________________________
□ O2 Inhalation _____liters/min
Rate: ________________________ Smoking:
□ Yes For how long: __________
Tube/Drainage: □ No
□ CTT □ Oral Airway
□ Endotracheal Tube □ Ventilator Comment:
______________________________________
Cough: □ Productive □ Non-productive ______________________________________
Sputum: □ Mucoid □ Bloody (hemoptysis) ______________________________________
□ Rusty □ Frothy ______________________________________
□ Thick Tenacious ______________________________________
Color: ____________________________ ______________________________________
______________________________________

Remarks

Nursing Diagnosis

C. CARDIOVASCULAR/CIRCULATORY SYSTEM

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Note: Assess heart sounds, rhythm, pulse, blood pressure, fluid retention and comfort.

Objective Subjective
Temperature: _______________ Celsius Previous/Recent Illness:
□ CVA □ CHF
Blood Pressure: Right_______ Left ________ □ MI □ Thrombophlebitis
□ Family History of HPN
Pulses: □ Renal Failure
Carotid Pulse: □ Thready □ Weak □ Bleeding Disorder
□ Strong □ Absent Comment:
Rate: Right______ Left______ ______________________________________
______________________________________
Apical: □ Regular □ Irregular Rate: ____ ______________________________________
______________________________________
Radial Pulse: □ Regular □ Irregular ______________________________________
□ Thready □ Weak _________________________
□ Strong □ Absent
Rate: Right______ Left _______ Do you experience any of the following:
□ Chest pain □ Arm pain
Dorsalis Pedis: □ Regular □ Irregular □ Leg pain □ Joint and Back
□ Thready □ Weak □ Dyspnea □ Orthopnea
□ Strong □ Absent □ Cough
Rate: Right_____ Left _____ □ Numbness and Tingling
□ Light headedness
Posterior Tibia: □ Regular □ Irregular □ Fatigue and weakness
□ Thready □ Weak □ Palpitations
□ Strong □ Absent Comment:
Rate: Right_____ Left _____ ______________________________________
______________________________________
Heart Rhythm: □ Tachycardia ______________________________________
□ Bradycardia
□ Arrhythmia/ Dysrhythmia Exercises:
Type: _________________________________
Jugular Veins Distention: Frequency: ____________________________
□ Positive □ Negative Duration: ______________________________

Nail bed Color : □ Pink □ Blue □ Pale Problem experience with usual activity and
exercise:
Capillary Refill: ________ (Normal less than 2 sec) Comment:
______________________________________
Edema: □ Pitting □ Non Pitting ______________________________________
Location: _____________________________
Factors Affecting Activity Intolerance:
Varicosities: □ Yes □ No Comment:
Location: ______________________________ ______________________________________
______________________________________
Calf Tenderness (Homan’s Sign): ______________________________________
Right □ Positive □ Negative ______________________________________
Left □ Positive □ Negative ______________________________________

Remarks

Nursing Diagnosis

D. INTEGUMENTARY SYSTEM

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Note: Assess skin integrity, color, temperature, turgor, hair distribution, nails.

Objective Subjective

Skin: □ Dry □ Intact Comment :

□ Warm □ Cold ______________________________________
□ moist ______________________________________
Turgor:________________________________ ______________________________________
______________________________________
□ Pallor □ Cyanosis ______________________________________
□ Jaundice □ Rashes ______________________________________
□ Acanthosis Nigricans □ Albinism ______________________________________
□ Erythema □ Edema
□ Petechia □ Itching
□ Drainage □ Swelling
□ Wound □ Decubitus Ulcer
□ Ecchymosis/hematoma

Temperature: _________
Comment:
Hair: □ Alopecia □ Hirsutism ______________________________________
□ Patchy hair loss ______________________________________
______________________________________
Distribution: ____________________________ ______________________________________

Nails: □ Dirty □ Pallor □ Cyanosis

□ Clubbing □ Paronychia □ Onycholysis Comment:
______________________________________
Capillary refill: __________ (Normal less than 2 sec) ______________________________________
Color: _________________ ______________________________________
______________________________________
______________________________________

Remarks

Nursing Diagnosis

E. ELIMINATION

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Objective Subjective
Mobility and Dexterity: Previous/Recent Surgery/Illness:
□ Ambulatory ______________________________________
□ Non-ambulatory ______________________________________
□ Bedridden
□ with assistive device History of pain and discomfort:
______________________________________
Tubes/Drainage/Stoma: ______________________________________
□ Colostomy
□ Ileostomy Diet: __________________________________
□ NGT
□ Catheter Personal Elimination
□ Suprapubic Catheter Habits:________________________________
______________________________________
Abdomen:
□ Soft □ Firm Elimination Problem:
□ Distended □ Non-distended □ Loose bowel movement □ Constipation
□ Fecal Incontinence □ Impaction
Bowel Sounds: (5 – 20 sounds/min) □ Neurologic Impairment □ Dysuria
□ Normoactive □ Urgency □ Polyuria
□ Hypoactive □ Oliguria □ Nocturia
□ Hyperactive(Borborygmi) □ Dribbling □ Incontinence
□ Absent □ Hematuria □ Retention □ Discharge
□ Residual urine (> 100ml)
Measurement:
Intake: ______________ Comment:
Output:_______________ ______________________________________
______________________________________
Edema: □ Yes □ No ______________________________________
Location: ______________________________
Medication taken:
Present Urine Color: ____________________ □ Analgesic Narcotic □ Antibiotics
□ Anticholinergic □ NSAID
Note: Assess urine frequency, color, odor control, □ Aspirin □ H2 antagonist
comfort/gyn-bleeding, discharge.
Fluid intake per day: __________ liters/day
Comment:
_______________________________________ Physical Activity: _______________________
_______________________________________ Comment:
_______________________________________ ______________________________________
_______________________________________ ______________________________________
_______________________________________
_______________________________________ Excessive Perspiration and Odor Problem:
_______________________________________ □ Yes □ No
________________
Stool
Consistency:___________________________

Remarks

Nursing Diagnosis

F. MUSCULOSKELETAL SYSTEM

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Note: Assess mobility, motion, gait, alignment, joint function, muscle tone, reflexes, comfort.

Objective Subjective

Mobility: □ Ambulatory Do you experience any of the following:

□ Non Ambulatory □ Lumbar pain □ Thoracic Pain □ Cervical
□ Bedridden Pain
□ Appliance ____________________ □ Joint pain
Comment
Gait and Posture: □ Lordosis □ Kyphosis ______________________________________
□ Scoliosis □ Shaftling □ Poliomyelitis ______________________________________
□ Amputated Limb ___________________ ______________________________________
______________________________________
Club foot (Talipes)
□ Varus □ Valgus
□ Equinovarus □ Calcanous Comment:
□ Use of Appliance __________________ ______________________________________
______________________________________
Muscle Tone/Strength: ______________________________________
□ Normal □ Slight weakness ______________________________________
□ Average weakness □ Poor ROM
□ Severe Weakness □ Paralysis Comment:
□ Atrophy □ Hyperatrophy ______________________________________
□ Spasm ______________________________________
______________________________________
Abnormal Findings:
□ Impaired ROM □ Joint swelling Comment:
□ Contractures/Deformities □ Crepitus ______________________________________
□ Tingling (Carpal Tunnel Syndrome) ______________________________________
□ Ankylosis □ Foot Drop ______________________________________
□ Pressure Ulcers ______________________________________
□ Urinary Elimination changes ______________________________________

Calf Tenderness (Homan’s Sign):

Right □ Positive □ Negative Comment:
Left □ Positive □ Negative ______________________________________
______________________________________
______________________________________
______________________________________
______________________________________

Remarks

Nursing Diagnosis

G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Note: Assess patient LOC, Sensation, pupillary size, orientation, vital signs, reflexes,

Objective Subjective
LOC: □ Alert □ Lethargic □ Comatose Check the Following Risk Factors:
□ Unresponsive □ Obtunded □ Stupor □ Older Adulthood □ Male □ Hx Stroke or
□ Decorticate □ Decerebrate TIA
□ Hypertension □ Smoking □ Hx CVD
GCS Score: _________ □ Sleep Apnea □ High level of Cholesterol
□ Drug Abused □ DM □ Oral
Cushing Triad (Respiratory changes, Increase Contraceptives
BP, Decreasing level of Consciousness) □ Menopausal □ Over weight
□ Positive □ Negative Comment:
____________________________________
Sensation: □ Positive □ Negative
Do you experience any of the following:
Pupillary Size: □ PERRLA □ Anisocoric □ Blurring □ Diplopia □ Photophobia
□ pain □ Inflammation □ Cataract
Orientation: □ Person □ Place □ Glaucoma □ Headache □ Unusual
□Time/Date Discharges
□ Pain Comment:
______________________________________
Sensory Function: □ Positive □ Negative ______________________________________
Location: ______________________________________
__________________________________ ______________________________________
______________________________________
Motor Function: □ Positive □ Negative ______________________________________
Location: ______________________________________
__________________________________ ______________________________________

Vital Signs: BP: _____T_____P_____R_____

Brudzinski’s sign: □ Positive □ Negative

Kernig’s Sign: □ Positive □ Negative

Reflexes:
Patellar □ Positive □ Negative
Biceps □ Positive □ Negative
Triceps □ Positive □ Negative
Achilles □ Positive □ Negative

Remarks

Nursing Diagnosis

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY