UNIVERSITY OF THE VISAYAS

College of Nursing
Banilad, Mandaue City

Introduction:

This manual deals with the application on the principles and techniques of nursing
care management of sick clients across lifespan with emphasis on the adult and the
older person, population group in any setting with alterations/problems in
oxygenation, fluid and electrolyte balance, nutrition and metabolism and endocrine
function.
Objectives: (General )

At the end of the course, and given actual clients with problems in oxygenation, fluid
and electrolyte balance, nutrition and metabolism, and endocrine function, the student should
be able to:
1. Utilize the nursing process in the care of individuals, families in community and
hospital settings.
Assess with client/s his/her/their condition/health status through interview, physical
examination, interpretation of laboratory findings
Identify actual and at-risk nursing diagnosis
Plan appropriate nursing interventions with client/s and family for identified nursing
diagnosis
Implement plan of care with client/s and family
Evaluate the progress of his/her/their clients condition ad outcomes of care
2. Ensure a well organized and accurate documentation system;
3. Relate with client/s and their family and the health team appropriately;
4. Observe bioethical concepts/ principles, core values and nursing standards in the
care of clients; and, 5. Promote personal and professional growth of self and others.
CHED MEMORANDUM ORDER (CMO) No. 14 Series of 2009 page# 71

Process on collecting the manuals:

1. Every clinical area has its own assessment manual.
2. Each student is given an individual client to care and to assessed.
3. One manual equivalent to one client.
4. A day prior to clinical duty, student has to assess client from the assigned area.
5. Manual should be submitted first day of their clinical duty.

MEDICAL ASSESSMENT TOOL

Date ________ Time ______
HEALTH HISTORY ( Fill in the basic information needed) 10pts.
I. General Data.
A. Personal Data

B. Chief Complaint

C. Past Health History (Past health problems, treatments & outcomes)

1. Surgical History (Type & date of surgery)

2. Medical Illnesses

D. Family History

E. Allergies

F. Current Medications

G. Activity of Daily Living (Hygiene, bladder & bowel elimination, activity

level, diet habits)

H. Health Practices

i. Lifestyle Habits

vascularCardio-

Nursing
Diagnosis

1. Observe for the respiratory rate & effort

2. Normal lung sounds (Area of the lung, type of sound, length of sound.)
3. Listen over the anterior, posterior chest of the client. Document if lung sounds are clear
anteriorly, posteriorly, and bilaterally
4. For abnormal lung sounds, Identify the caused of the abnormal sounds.
5. If productive cough is present, note the following for color, amount, & consistency

Nursing
Diagnosis

1.Mobility Status:

etalMusculoskel

1. Assess for muscle strength; Any atrophy?; Walking ability or transfer ability?; Joint mobility
( Full range of motion / Limited range of motion)
2. Evaluate if there is muscle or joint pain.

Nursing
Diagnosis

Neurological

2.Assistive Devices
3.Limitations
4. Do you have enough energy for desired activity?
5.Activities of Daily Living:

Nursing
Diagnosis

1.
2.
3.
4.
5.
6.

Nursing
Diagnosis

PerceptualSensory-

monaryCardipul

Auscultate the Apical Heart sounds caused by closure of the 4 heart valves. Check for abnormal
heart sounds.
Palpate the peripheral pulses.
Check the capillary refill time.
Does client complained of chest pain?

Respiratory

II. SYSTEMS ASSESSMENT. ( Write the findings based on your IPPA). 10pts

1. Functional ability of the eyes & ears

2. Appearance of the eyes & ears

Note the appearance, hygiene, speech, & behavior

Note clients mood, facial expression, ability to verbally communicate, and intellectual ability
Level of Consciousness
Level of Orientation
Pupillary reaction (Note the size & shape of pupils)
Strength of Hand grasp

rymentaIntegu

Color of the skin & mucous membrane

Skin temperature
Any lesions? Note the (Location, size, shape, drainage of all wounds)
Skin Turgor
Edema

Nursing
Diagnosis

1. Check & observe the mouth

2. Abdomen: Auscultate bowel sounds; Describe the bowel sounds; Palpate abdomen & note;
describe any stools during your shift.
3. Check for hemorrhoids

Nursing
Diagnosis

1.
2.
3.
4.

Nursing
Diagnosis

eductivRepro

ationElimin

nalIntesti-Gastro

1. Special Diet :
2.Frequency of Meals:
3.Recent changes in appetite / eating / patters ?
4.Have you experienced any of the following? Describe & How often ?
5.Recent Weight Loss / Gain ?

Nursing
Diagnosis

yurinarGenito

olicMetabonal /Nutriti

1.
2.
3.
4.
5.

Describe urine( color, amount, & frequency)

Note for any difficult in urination
Any perineal lesions?
Palpate the lower abdomen, check if bladder is palpable

1. Bowel:
2. Bladder:

Male:

Inspect for any abnormality; discharges; pain

Female

Check for any bleeding; pain

Pap smear last taken

Nursing
Diagnosis

Nursing
Diagnosis

Nursing
Diagnosis

Stress/ Coping
RestSleep/
tionPercepSelfBeliefs/Values

1. Have you had any recent changes in your life (job, divorce,death,major surgeries,recent
abuse)?
2. Do you feel you are dealing successfully with stresses associated with this change?

1.Sleep: Any problem with sleeping pattern?

2. What helps you sleep?

1. What concerns you most about your illness/hospitalization?

2. Does your illness and /or hospitalization affect your sexuality/body image?

1. Is religion important in your life?

Nursing
Diagnosis

Nursing
Diagnosis

Nursing
Diagnosis

Nursing
Diagnosis

Reference : Rick Daniels;Ruth N.Grendell;Fredrick R. Wilkins; Nursing Fundamentals Caring and

Clinical Decision Making;;Second Edition;Delmar Cengage Learning 2010.

INTERPRETATION OF CLIENT'S LABORATORY / DIAGNOSTIC RESULTS

( Write all the clients laboratory / diagnostic findings and the significance of the result) 5pts
Laboratory
Diagnostic

Date
Performe
d

Actual Result

Normal Value

Significance of the

(Reference)

Result

NURSING SYSTEMS REVIEW