PATIENT CHARTING

ASSESSMENT
SUBJECTIVE:
“sobrang sakit ng ulo ko” as verbalized by the patient.
OBEJECTIVE:
• Left sided weakness.
• Right frontal intracranial hemorrhage.
• GCS OF 15
• VITAL SIGNS AS FOLLOWS:
BP- 130/79 mmHg
PR- 63 BPM
RR- 20
Oxygen sat- 98%
DIAGNOSIS
Knowledge deficiency related to unfamiliarity with information resources as evidenced by the statement
of the problem/concerns, misconceptions.
PLANNING
After 8 hours of proper Nursing Intervention the patient will Verbalize understanding of disease
process/perioperative process and postoperative expectations.
INTERVENTION
1. Assess patient’s level of understanding.
2. Review specific pathology and anticipated surgical procedure. Verify that appropriate consent has
been signed.
3. Use resource teaching materials, audiovisuals as available.
4. Preoperative instructions: NPO time, shower or skin preparation, which routine medications to
take and hold, prophylactic antibiotics, or anticoagulants, anesthesia premedication.
5. Intraoperative patient safety: not crossing legs during procedures performed under local or light
anesthesia.
6. Discuss individual postoperative pain management plan. Identify misconceptions patient may
have and provide appropriate information.
7. Provide opportunity to practice coughing, deep-breathing, and muscular exercises.
EVALUATION
After 8 hours of proper Nursing Intervention the patient Verbalized understanding of disease
process/perioperative process and postoperative expectations.
GOAL MET

PATIENT EDUCATION
 Increase your activity slowly. Talk with your healthcare provider about which activities you can
start with.
 Don’t drive until your healthcare provider says it’s OK.
 Don’t lift anything until your healthcare provider says it’s OK. Your provider may tell you not to
lift more than 10 pounds (4.5 kg) for a period of time.
 Take your medicine exactly as directed.
 Shower as needed. But keep your incision dry. You can wash your hair with mild soap after your
stitches or staples have been removed.
 Don’t put creams, lotions, or other ointments to your incision unless your provider tells you to.
Keeping the incision clean and dry will help it to heal quickly. Most stitches or staples in the
scalp are removed in 7 to 10 days.
 Don't drink alcohol or use recreational drugs.
 Get plenty of rest and sleep.
 Don't take aspirin, ibuprofen, or similar medicines unless your healthcare provider says it's OK. 
 Make a follow-up appointment.
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: N/A Age: 21-YEAR-OLD Date of Birth: N/A

Medical Diagnosis: INTRACRANIAL HEMORRAGE UNDERGONE CRANIOTOMY

Nursing Diagnosis: Knowledge deficiency related to unfamiliarity with information resources as evidenced by
the statement of the problem/concerns, misconceptions.

Assessed by: ROMERO, DEINIELLE INGRID M. Date of Assessment: N/A Time: N/A

Assessmen
Area t Description of Findings & Interpretation
N AbN
General Appearance ✓ DUE TO LEFT SIDED WEAKNESS
Posture
Hygiene/Grooming ✓
Nutrition/Diet ✓
Body Size/Habitus ✓
Height: ________ ✓
Weight: _______ ✓
Supply appropriate data: N/A
 IBW: ___________
 BMI: ___________ N/A
 IRS: ____________ N/A
Behavior ✓ RESTLESNESS DUE TO CRANIOTOMY
LOC ✓ LOW LEVEL OF CONCIOUSNESS DUE TO CRANIOTOMY AND
INCREASE ICP
Vital Signs ✓
Temperature: 95.5 F
Pulse Rate: 63 ✓
Rhythm:
Respiration Rate: 20 ✓
Rhythm: ___________
Blood Pressure: 130/79 mmHg ✓
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 ✓ UNDERGONE CRANIOTOMY
Shape & Symmetry
Unusual swelling ✓ UNDERGONE CRANIOTOMY
Cranial bruit ✓ UNDERGONE CRANIOTOMY

Form No.: TSU-COS-

Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
SF-

Assessmen
Area t 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:__________
 Effectivity Date: June 22,
Form No.: TSU-COS-SF- Revision No.: 00 Page 2 of 6
2016

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 N/
A
Breath Sound (Specify)
a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus
CTT N/
Location: __________ A
Suction: ___________
Water Level: _______
Quality of Drainage: ___________
ABG
Other Findings: ________________
Heart N/
History A
With Palpitation
 Dyspnea
Rhythm
Point of Maximal Impulsec(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- Revision No.: Effectivity Date: June 22,

Page 3 of 6
SF- 00 2016

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 ✓ FRACTURE DUE TO LIFTING WEIGHTS
 Spine
 Paralumbar ✓ FRACTURE DUE TO LIFTING WEIGHTS
Other Findings: ________________
Genitalia N/
A
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- Revision No.: Effectivity Date: June 22,
Page 4 of 6
SF- 00 2016

Assessment
 N AbN
Area Description of Findings & Interpretation

Rectal Examination N/
Anal Inspection A
With Hemorrhoids: Yes:__ No:__
Location: ______________
Characteristics: _________
Mass
Last Bowel Movement: _________
Characteristic of Stool: __________
Other Findings: ________________
Nodes N/
Lymphadenopathy A
Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________
Extremity N/
Texture A
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- Revision No.: Effectivity Date: June 22,
Page 5 of 6
SF- 00 2016

Assessment
Area N AbN Description of Findings & Interpretation

Hematopoietic N/
Easy Bruisability A
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings: ________________
Neurology
Assessment of Cranial Nerves
 CN I (Olfactory)
 CN II (Optic) ✓ THIS NERVE WAS AFFECTED DUE TO CRANIOTOTMY AND
 CN III (Oculomotor) BRAIN SWELLING PLUS BLURRY VISION
 CN IV (Trochlear) ✓ THIS NERVE WAS AFFECTED DUE TO CRANIOTOTMY
 CN V (Trigeminal)
✓ THIS NERVE WAS AFFECTED DUE TO CRANIOTOTMY
  CN VI (Abducens) ✓ THIS NERVE WAS AFFECTED DUE TO CRANIOTOTMY
 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