P.A Tool

Name: ________________________________________
Year/Section: __________________________________
Date of Submission: _____________________________
Clinical Instructor: ______________________________
Score: ___________________
PHYSICAL ASSESSMENT TOOL

1. PROFILE
Name: __________________________________________________
Address: ________________________________________________
Date of Admission: ___________________ Time: _______________
_______
Arrived via:
Wheelchair
Stretcher
Ambulatory
Admitting M.D. ______________________
Source Providing Information:
Patient
Other: ______________
II.
Age: ________ Sex: __________

Status: ____________________
Weight: ______ Height:
Temp: _______ Pulse: ________
RR: _________ BP: ___________
NURSING HISTORY
A. Chief Complain (Onset, Duration, Pt.s Perception):

_______________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
________
B. History of Present Illness (HPI) (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms,
previous treatment and results, social and vocational responsibilities, affected diagnosis)
I. Past Medical History

a. General State of Health
b. Childhood Illness
c. Adult Illness
d. Psychiatric Illness
e. Accidents and Injuries
f. Surgeries
g. Hospitalizations
D. Current Medical Status
a. Current Medications
b. Allergies
c. Tobacco (frequency, amount, duration)
d. Alcohol, drugs and related substance (frequency, amount, duration)
e. Diet
f. Screening Test
g. Immunizations
h. Exercise and Leisure Activities
i. Sleep Patterns
j. Environmental Hazards
k. Use of Safety Measures
E. Family History with Genogram
Heredo-familial disease
Diabetes
Heart Disease
Hypertension
Stroke
Cancer
Arthritis
Rheuma
Allergies
Asthma
Epilepsy
Mental Illness
Other (Please specify)
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Acquired Diseases:
Hypercholestereloremia______
Kidney Disease
______
Tuberculosis
______
Alcoholism
______
Drug addiction
______
Hypertension
______
Hepatitis A
______
B
______
C
______
Other (Please Specify) ______
Diagram (with legend)
F.
Psychological History
a. Home Situation and Significant Others
b. Daily Life
c. Important Experiences
d. The Patients Outlook
III.
REVIEW OF SYSTEM
Weight: ______________
Height: ____________
Temp: ___________ PR: _____________ RR:
____________ BP: ____________
General Condition
Integumentary
HEENT
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Excretory
Endocrine
Musculoskeletal
Neurological
Reproductive
IV.
SUMMARY OF INTERACTION
NURSING ASSESSMENT
Name: ______________________________________________________________________________
Age ______________
Sex
_____________
Chief Complain:
________________________________________________________________________________________________________________________________________________
________________________________________
Impression/Diagnosis:
________________________________________________________________________________________________________________________________________________
__________________________________
Date of Admission _____________________________________________________________________
Inclusive Dates of Care
_____________________________________________________________
Diet
________________________________________________________________________________________________________________________________________________
__________________________________________________
Type of Operation (if any)
________________________________________________________________________________________________________________________________________________
_______________________________
Normal Pattern
Before Hospitalization
Initial
Clinical Appraisal
Day 1
Day 2
1. ACTIVITIES
REST
A. Activities
B. Rest
C. Sleeping
Pattern
2. NUTRITIONAL
METABOLIC
PATTERN
A. Typical Intake
(food, fluid)
B. Diet
C. Weight
D. Medications/Su
pplement
3. ELIMINATION
PATTERN
A. Urine
(frequency,
color,
transparency)
B. Bowel
(frequency,
color,
transparency)
4. EGO INTEGRITY
A. Perception of
Self
B. Coping
Mechanism
C. Support System
D. Mood/Affect
5. NEURO
SENSORY
A. Mental State
B. Conditions of 5
senses (sight,
hearing, smell,
taste, touch)
6. OXYGENATION
A. Vital Signs
Pulse Rate
Heart Rate
Blood Pressure
B. Lung Sounds
C. History of
Respiratory
Problems
7. PAIN COMFORT
A. Pain (location,
onset,
character,
intensity,
duration,
associated
aggravation)
B. Comfort
Measures /
Alleviation
C. Medications
8. HYGIENE AND
ACTIVITIES OF
DAILY LIVING
Sexuality
Reproductive
Pattern
A. Female
(Menarche,
Menstrual Cycle,
Civil Status,
Number of
Children)
B. Male
(Circumcision,
Civil Status,
Number of
Children)
LABORATORY AND DIAGNOSTIC PROCEDURE

DATE
NAME OF PROOCEDURE
RESULT
NORMAL VALUE
NURSING IMPLICATION
DRUG STUDY
Brand Name
Generic Name
Classification
Prescribed and
Recommended
Dosage,
Frequency, and
Route of
Administration
Mechanism of
Action
Indication
Contraindication
Adverse Reaction
Nursing
Responsibilities
DRUG STUDY
Brand Name
Generic Name
Classification
Prescribed and
Recommended
Dosage,
Frequency, and
Route of
Administration
Mechanism of
Action
Indication
Contraindication
Adverse Reaction
Nursing
Responsibilities
NURSING CARE PLAN

CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN
Patients Name _____________________________________________________________________
______________________________________________________
Condition Upon Discharge ____________________________________________________________
Request ( ) Discharge Against Medical Advice ( )
1. MEDICATIONS
Date of Discharge
Nature: Home per
2. EXERCISE
3. DIET
4. HEALTH TEACHING
5. SCHEDULE OF NEXT VISIT
SUMMARY OF INTRAVENOUS FLUIDS

DATE AND TIME STARTED
INTRAVENOUS SOLUTION
PRESCRIBED RATE
HOURS TO RUN
DATE AND TIME

CONSUMED
NURSING CARE PLAN

CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
NURSING CARE PLAN

CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION

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Name: ________________________________________

PHYSICAL ASSESSMENT TOOL

Age: Sex: __

A. Chief Complain (Onset, Duration, Pt.s Perception):

I. Past Medical History

LABORATORY AND DIAGNOSTIC PROCEDURE

NURSING CARE PLAN

ANATOMY AND PHYSIOLOGY

5. SCHEDULE OF NEXT VISIT

SUMMARY OF INTRAVENOUS FLUIDS

DATE AND TIME

NURSING CARE PLAN

NURSING CARE PLAN

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