TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
DAILY PHYSICAL EXAMINATION REPORT
Name of Patient: ___________________________________Age: __________Date of Birth: __________________
Medical Diagnosis: _____________________________________________________________________________
Nursing Diagnosis: _____________________________________________________________________________
Assessed by: ___________________________Date of Assessment: _________________Time: _______________
Assessment
Area Description of Findings & Interpretation
N AbN
General Appearance
Posture
Hygiene/Grooming
Nutrition/Diet
Body Size/Habitus
Height: ________
Weight: _______
Supply appropriate data:
➢ IBW: ___________
➢ BMI: ___________
➢ IRS: ___________
Behavior
LOC
Vital Signs
Temperature: ________
Pulse Rate: _________
Rhythm: __________
Respiration Rate: ________
Rhythm: ___________
Blood Pressure: __________
Skin
Color
Temperature
Turgor
Texture
Integrity
Unusual Marks
Rashes, Lesions
Pressure sore: Yes ___ No ___
Site: ___________________
Edema: Yes ____ No ____
Site: _____________________
Type: _____________________
Size/Degree: _______________
Hair
Texture
Thickness
Color & Distribution
Hygiene Status
Nails
Color & Shape
Hygiene Status
Presence of Clubbing
Head
Shape & Symmetry
Unusual swelling
Cranial bruit
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
Assessment
Area Description of Findings & Interpretation
N AbN
Eyes
Size, placement & alignment
Cornea
Pupils
➢ Size (mm)
PERRLA
Visual Acuity
Orbital Bruit
Other Findings: __________________
Ear
Location/Alignment
Pinna, Cannals, Drums
Hygiene
Discharge and Odor
Hearing Acuity
Tinnitus
Vertigo/Dizziness
Other Findings: __________________
Nose
Shape
Symmetry
Patency
Mucosal Integrity
Epistaxis
Sinuses
Other Findings: __________________
Lips
Integrity
Symmetry
Color
Other Findings: __________________
Mouth
Hygiene
Number & Condition of Teeth
Gums
Mucosal Integrity
Tongue
Tonsils
Palate
Parotid Gland
Hoarseness
Other Findings: __________________
Neck
Carotid Bruit
Neck Veins
Thyroid
Trachea Rigidity/Tenderness
Mass/Bruises
Other Findings: __________________
Chest and Lungs
Shape & Symmetry
➢ Nipple & Areola
➢ Mass/Lump
➢ Others: _____________________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 2 of 6
Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Breathing
➢ Spontaneity
➢ With Ventilator
➢ With Tracheostomy
➢ Rhythm
➢ Depth
➢ Effort
Use of Accessory Muscles
a. Intercostals
b. Abdominal
c. Sternocleidomastoid
d. Trapezius
Cough
Sputum Production: Yes __ No: __
➢ Amount: _____________
➢ Consistency: __________
➢ Color: _______________
➢ Odor: _______________
Chest X-ray Result
Breath Sound (Specify)
a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus
CTT
Location: __________
Suction: ___________
Water Level: _______
Quality of Drainage: ___________
ABG
Other Findings: ________________
Heart
History
With Palpitation
Dyspnea
Rhythm
Point of Maximal Impulse (PMI) (PMI
is felt at 5th ICS at apex of heart)
Specify:
a. Heaves
b. Clicks
c. Splitting
d. Thrills
e. Callops
f. Muffles
Presence of Heart Sounds
a. S1
b. S2
c. S3
d. S4
Murmurs
a. Systolic
b. Diastolic
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 3 of 6
Assessment
Area N AbN Description of Findings & Interpretation
Abdomen
Diet: __________________________
Mode of Feeding: ________________
Shape and Symmetry
Umbilicus Protrusion
Bowel Sound (Indicate Sound)
➢ LUQ: ___________________
➢ RUQ: ___________________
➢ LLQ: ___________________
➢ RLQ: ___________________
Abdominal Bruit
Distention
Ascites: Yes: ________ No: _______
Nausea
Vomitus/Hematemesis
Amount: _______________________
Consistency: ____________________
Color: _________________________
Odor: _________________________
Frequency: _____________________
Drainage Tube
Abdominal Mass
Abdominal Girth: ________________
Other Findings: __________________
Back
➢ Spine
➢ Paralumbar
Other Findings: __________________
Genitalia
Symmetry
Presence of Tenderness
Urethral Discharge
Bleeding
Pelvic Pain
LMP: _________________________
With Dysuria
With Flank Pain
Nocturia
History of Urinary Stone
History of Impotence
With Urinary Catheter
Urinalysis Finding: _______________
Peritoneal Dialysis (PD)
a. Date Started ________________
b. Incorporation _______________
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________
Hemodialysis
Frequency: _____________________
Last HD: _______________________
Amount of Fluid Removed: ________
Next HD: ______________________
Place: _________________________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 4 of 6
Assessment
Area Description of Findings & Interpretation
N AbN
Rectal Examination
Anal Inspection
With Hemorrhoids: Yes:___ No:____
Location: ______________________
Characteristics: _________________
Mass
Last Bowel Movement: _________
Characteristic of Stool: __________
Other Findings: ________________
Nodes
Lymphadenopathy
Location
a. Cervical R _____ L _____
b. Axillary
c. Inguinal R _____L ______
Others ________________________
Extremity
Texture
Capillary Refill
Peripheral Pulse (both sides)
➢ Carotid
➢ Radial
➢ Ulna
➢ Brachial
➢ Femoral
➢ Posterior Tibial
➢ Dorsalis Pedis
➢ Popliteal
Clubbing of Fingers
Varicosities
Thrombophlebitis
Cyanosis
Joints
➢ Erythema
➢ Tenderness
➢ Deformity
➢ Swelling
Muscles
➢ Bulk
➢ Tone
➢ Tenderness
Ulcerations
Edema
Other Findings: _________________
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 5 of 6
Assessment
Area Description of Findings & Interpretation
N AbN
Hematopoietic
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings:
__________________
Neurology
Assessment of Cranial Nerves
➢ CN I (Olfactory)
➢ CN II (Optic)
➢ CN III (Oculomotor)
➢ CN IV (Trochlear)
➢ CN V (Trigeminal)
➢ CN VI (Abducens)
➢ CN VII (Facial)
➢ CN VIII (Vestibulocochlear)
➢ CN IX (Glossopharyngeal)
➢ CN X (Vagus)
➢ CN XI (Spinal Accessory)
➢ CN XII (Hypoglossal)
Motor and Posture
Sensory Perception
Reflexes
a. Indicate Type of
Reflex___________________
________________________
b. Pathologic Reflex:
Yes_______ No______
Other Findings: _________________
Patient’s ADL
a. Bathing
b. Dressing
c. Elimination
d. Mobility and Movement
e. Nutrition and Feeding
Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
LABOR ROOM / DELIVERY ROOM & NURSERY SLIP
Name of Hospital / Agency: _______________________________________________
Date: ________________________ Shift: _____________________
Name of Student: ______________________________________________________
Name of Patient:
_____________________________________________________________________
First Name Middle Name Last Name
Case Number: ____________________ Time Started: ____________________
Age: ____________ Sex: (For the Newborn) ____________
Procedure Performed:
______________________________________________________________________
LR/DR Nurse On Duty / Nursery Nurse on Duty
______________________________________________________________________
First Name Middle Name Last Name
License Number: _________________ OR Nurse: DR Nurse
Signature: _____________________ Signature:
Clinical Instructor
Name:
______________________________________________________________________
License Number: __________________________ Signature: ___________________
Form No.: TSU-COS-SF-06 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
Republic of the Philippines Republic of the Philippines
TARLAC STATE UNIVERSITY TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE COLLEGE OF SCIENCE
Department of Nursing Department of Nursing
LR/DR & ICNB Slip LR/DR & ICNB Slip
Health Care Agency: ________________________________________ Health Care Agency: ________________________________________
Date: __________ Shift: ________________ Date: ___________ Shift: ________________
Name of Student: __________________________________ Name of Student: __________________________________
Name of Patient: Name of Patient:
First Name Middle Name Family Name First Name Middle Name Family Name
Case Number:_________________ Case Number:_________________
Time Started: ________________ Time Started: ________________
Age:_______ Age:_______
Sex (for newborn):____________ Sex (for newborn):____________
Procedure Performed: ______________________________________ Procedure Performed: ______________________________________
LR-DR/ Nursery Nurse on Duty: LR-DR/ Nursery Nurse on Duty:
First Name Middle Name Family Name First Name Middle Name Family Name
License Number: ______________ Signature: ___________________ License Number: ______________ Signature: ___________________
Clinical Instructor: _________________________________________ Clinical Instructor: _________________________________________
License Number: ______________ Signature: ___________________ License Number: ______________ Signature: ___________________
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
IMMEDIATE NEWBORN CARE in _______________________________________________
Hospital/Home/Lying – in Clinic, Municipality/City/Province
Prepared by:
________________________________ ICNB FORM
Printed Name and Signature of Student IMMEDIATE CARE OF THE
NEWBORN
PATIENT’S INITIAL SURGICAL SUPERVISED BY
DATE PERFORMED ONLY O.R. NURSE ON DUTY CLINICAL
PROCEDURE
AND CASE NUMBER (Name and Signature) INSTRUCTOR
PERFORMED (if Midwife on Duty, signature
(Not applicable for (Name and Signature)
TIME STARTED Birthing/Lying – in
Indicate where performed (e.g., not required)
D.R., Nursery, NICU or Homes)
Clinics/Homes)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
ACTUAL DELIVERY in _______________________________________________
Hospital/Home/Lying – in Clinic, Municipality/City/Province
Prepared by:
________________________________
DR FORM
Printed Name and Signature of Student
ACTUAL DELIVERY FORM
PATIENT’S INITIAL SUPERVISED BY
DATE PERFORMED ONLY SURGICAL O.R. NURSE ON DUTY CLINICAL
AND CASE NUMBER PROCEDURE (Name and Signature) INSTRUCTOR
TIME STARTED (Not applicable for PERFORMED (if Midwife on Duty, signature (Name and Signature)
Birthing/Lying – in not required)
Clinics/Homes)
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Name Area
Inclusive dates
Year Level RLE Group
of Rotation
PARAPHERNALIA CHECKLIST
Items / Date
Sphygmomanometer
Stethoscope
Small ruler
Penlight
Thermometer (Digital) – 2
Medicine cup
Medicine tray
Surgical gloves – clean
Surgical gloves – sterile
Tongue depressor
Tape measure
Kidney basin
Mask
Syringes (1cc, 3cc, 5cc, 10cc)
Logbook
Pencil
Eraser
Sharpener
Ballpens (blue/black, red, green)
Dry cotton balls
Wet cotton balls(with alcohol)
Alcohol
Betadine
Bandage scissor
Torniquet
Hypoallergenic/Micropore tape
Gauze
Hand towel
Soap
NANDA Handbook
Forms:RLE Notice
Skills Inventory
Physical Assessment
Performance Evaluation
Rubrics for Charting
Others: LR/DR/NB slip
OR slip
PRC form
REMARKS
_________________________
Clinical Instructor
Form No.: TSU-COS-SF-08 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
PATIENT EDUCATION FORM
Name Area
Inclusive
Year
RLE Group dates of
Level
Rotation
Name of
Age Gender
Patient
Date
Diagnosis
Admitted
MAIN CONCEPT / TOPIC:
Details of Patient Education Content:
Patient’s Signature / Significant Other’s
Signature
Date Signed
Date Submitted
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
CLINICAL CASE ANALYSIS
Name of Patient Age: Gender:
Address Date
Admitted
Diagnosis
NURSING HISTORY
PATHOPHYSIOLOGY
DIAGNOSTIC PROCEDURES
MEDICAL MANAGEMENT
Name of
Student
Date Submitted C.I.’s Signature
Form No.: TSU- Effectivity Date: June 22,
Revision No.: 00 Page 1 of 1
COS-SF-04 2016
