FORM D

REPORT OF PRACTICAL EXPERIENCE

I. Demographic Data
Pt. Name : _________________________________________________________________
Room/ Bed # : _________________________________________________________________
Medical Record # : _______________________
Age : year(s) month(s) week(s) day(s)
Gender : male female
Marital status : single married divorced
Address : _________________________________________________________________
Occupation : _________________________________________________________________
Religion : ______________________
Medical Diagnosis : _________________________________________________________________
Physician Name : dr.___________________
II. Definition of Disease**





Reference(s):
III. Etiology*














Reference(s):

Name:___________________
Submit Date:___________________
Week:___________________
Department:___________________

*must be with references
**must be with at least two references

IV. Signs and Symptoms*
Signs and Symptoms Theoretical Practical

V. Pathophysiology*















*must be with references

VI. Assessment
A. Health History
1. Chief Complaints (PQRST)
P :
Q :
R :
S :
T :
2. History of Present Illness



3. Past History
a. Childhood Illness :

b. Accident(s)
i. Type :
ii. Date/month/year :

c. Allergy :

d. Hospitalization(s)
i. Cause(s) :
ii. Date/month/year :

e. Medications :

4. Family History (3 Generations Genogram)



















Legend:
= Female
= Male
= Dead Female
= Dead Male
= Pt (male)
= Pt (female)
= Divorced
= Twin
= Adopted
5. Lifestyle
LIFESTYLE PAST PRESENT
Diet Pattern
Food

Amount :
Frequency :
Contents :
Others (specify):
Amount :
Frequency :
Contents :
Others (specify):
Nursing Dx.
Imbalanced Nutrition : More than body requirements
Imbalanced Nutrition : Less than body requirements
Others : ____________________________________________________________________________
Liquid

Amount :
Frequency :
Contents :
Others (specify):
Amount :
Frequency :
Contents :
Others (specify):
Nursing Dx.
Deficient Fluid Volume
Excessive Fluid Volume
Others : ____________________________________________________________________________
Sleep and
Rest Pattern

Average sleep duration:
Sleep quality:
Sleep well Frequently awakened (__x)
Sleeping position : _____ ______ pillows
Supine Semi Fowlers High Fowlers
Others (specify)____________
Average sleep duration:
Sleep quality:
Sleep well Frequently awakened (__x)
Sleeping position : _____ ______ pillows
Supine Semi Fowlers High Fowlers
Others (specify)____________
Nursing Dx.
Disturbed Sleep Pattern
Others : ____________________________________________________________________________
Elimination Pattern
Bowel

Amount :
Frequency :
Consistency :
Others (specify):
Amount :
Frequency :
Consistency :
Others (specify):
Nursing Dx.
Constipation
Diarrhea
Bowel Incontinence
Others : ____________________________________________________________________________
Urination

Amount : Frequency :
Color : Odor :
Nocturia Bladder Distention
Amount : Frequency :
Color : Odor :
Nocturia Bladder Distention
Nursing Dx.
Urinary Incontinence
Others : ____________________________________________________________________________
Activities of
Daily Livings
Fulfilled independently
Fulfilled with assistance
Fulfilled independently
Fulfilled with assistance
Nursing Dx.
Activity Intolerance
Others : ____________________________________________________________________________
Hobbies and
Recreation
Type :
_____________x/week
Type :
_____________x/week
Nursing Dx.
Activity Intolerance
Others : ____________________________________________________________________________
B. Physical Examination
1. Vital Signs
T : ___C P :___x/m R :___x/m BP: ____mmHg Weight: _____kg
Nursing Diagnoses:
Hypothermia
Hyperthermia
2. Glasgow Coma Scale and Level of Consciousness
P PA AR RA AM ME ET TE ER R F FI IN ND DI IN NG G S SC CO OR RE E
E Ey ye e o op pe en ni in ng g S Sp po on nt ta an ne eo ou us sl ly y
4 4
T To o s sp pe ee ec ch h
3 3
T To o p pa ai in n
2 2
D Do o n no ot t o op pe en n
1 1
B Be es st t v ve er rb ba al l
r re es sp po on ns se e
O Or ri ie en nt te ed d
5 5
C Co on nf fu us se ed d
4 4
I In na ap pp pr ro op pr ri ia at te e s sp pe ee ec ch h
3 3
I In nc co om mp pr re eh he en ns si ib bl le e s so ou un nd ds s
2 2
N No o v ve er rb ba al li iz za at ti io on n
1 1
B Be es st t m mo ot to or r
r re es sp po on ns se e
O Ob be ey ys s c co om mm ma an nd d
6 6
L Lo oc ca al li iz ze es s p pa ai in n
5 5
W Wi it th hd dr ra aw ws s f fr ro om m p pa ai in n
4 4
A Ab bn no or rm ma al l f fl le ex xi io on n
3 3
A Ab bn no or rm ma al l e ex xt te en ns si io on n
2 2
N No o m mo ot to or r r re es sp po on ns se e
1 1


I In nt te er rp pr re et ta at ti io on n: : B Be es st t s sc co or re e = = 1 15 5; ; d de ee ep p c co om ma a = = 3 3; ; 7 7 o or r l le es ss s
g ge en ne er ra al ll ly y i in nd di ic ca at te es s c co om ma a; ; c ch ha an ng ge es s f fr ro om m b ba as se el li in ne e a ar re e
m mo os st t i im mp po or rt ta an nt t. .
Level of Consciousness :
Compos Mentis Apathy Somnolence Stuppor Coma
Nursing Diagnoses:
Deficient Fluid Volume
Imbalanced Nutrition: More than body requirements
Skin Integrity, Impaired
Ineffective Airway Clearance
Self-care Deficits
Risk of Aspiration
Communication, Impaired Verbal
______________________________________________________________________
3. Head and neck
a. Head mesocephal nodule lesions scar hematoma bruits sound
normal sinuses tenderness pain facies leonine deformities
pale _______________ _________________ ________________
Trigeminal (V) nerve function positive negative
Hair scaly dry oily fall bald ____________________
Temporal artery weak strong regular irregular absent
Total: ____

&
face
b. Eye conjunctiva anemis exophtalmos enophtalmos ptosis glaucoma
sunken eyeball icterus strabismus ulcer deviation conjugee
nystagmus cataract retinopathy papilledema emmetropia
myopia hyperopia presbyopia astigmatism photophobia
foreign body eyeglasses contact lens excessive tearing
inflammation hemorrhage exudates edema entropion
ectropion lagophtalmos redness aphakia swelling ____________
Pupil P E R R L A mydriasis constricted isochors
Abduscence (VI) nerve function positive negative
c. Ear symmetrical lesions thickening exudates odor pain redness
tenderness deformities __________________ ___________________
d. Nose symmetric deformities lesions exudates obstruction pink moist
red inflammation purpuration ____________ __________________
Olfactory (I) nerve function positive negative
e. Mouth caries dentures indurations scaly ulcer nodules cracks moist
pink cyanosis redness inflammation _________ ____________
No. of teeth:____________
Hypoglossal (XII) nerve function positive negative
Glossopharyngeal (IX) + Vagus (X) nerve function positive negative
Facial (VII) + glossopharyngeal (IX) nerve function positive negative
f. Throat and neck
symmetrical swelling masses pain on movement bruits sound
Jugular vein(s) distention pain on swallowing ____________________
Shoulder resistance weak strong
Lymph nodes small soft tender movable enlarged
Trachea midline symmetrical deformities deviation
Carotid artery weak strong regular irregular absent
Nursing Diagnoses:
Deficient Fluid Volume
Infection, Risk for
Imbalanced Nutrition: More than body requirements
Hyperthermia
Swallowing, Impaired
Oral Mucous Membrane, Impaired
Skin Integrity, Impaired
Acute/Chronic Pain
Ineffective Airway Clearance
______________________________________________________________________




4. Chest
a. Inspection accessory respiratory muscle use lesions symmetrical thorax
redness scar dry skin warm squama swelling
gynecomastia retraction Barrel chest _________ ________
Breast symmetrical smooth extreme vascularity retraction
bulging discharge bleeding scaly indurations masses
______________
b. Palpation
Apical pulse weak strong regular irregular absent
Tactile fremitus normal increased decreased
c. Percussion resonance hyper-resonance dullness tympani
Diaphragmatic excursion 3-5 cm < 3 cm >5 cm *(______cm)
d. Auscultation bronchovesicular vesicular bronchial tubular/tracheal
crackles wheezing _________________ _______________
Nursing Diagnoses:
Skin Integrity, Impaired
Activity Intolerance
Cardiac Output, Decreased
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
Self-care Deficit
Tissue Perfusion, Altered
Acute/Chronic Pain
______________________________________________________________________
5. Upper Extremities
a. Inspection anemia jaundice hyper-pigmented vitiligo striae cyanosis
clubbing finger onycholysis ulcer sikatriks nevi deformities
spider nevi hirsutism ecchymosed paronychia ____________
b. Palpation warm tenderness poor skin turgor ____________ ___________
Brachial pulses weak strong regular irregular absent
Radial pulses weak strong regular irregular absent
Ulnar pulses weak strong regular irregular absent
Capillary refill normal slow






Senses Left Right
Light/Deep Touch
Sharp/dull
Warm/cold
Vibrations
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
c. Percussion :



Nursing Diagnoses:
Acute/Chronic Pain
Skin Integrity, Impaired
Tissue Perfusion, Altered
Disturbed Body Image
Coping, Ineffective
Infection, Risk for
_____________________________________________________________________
6. Abdomen
a. Inspection symmetrical bulges flat rounded ascites deformities
incision __________ ___________
Umbilicus midlined inverted
b. Auscultation
Bowel sounds
o RLQ hyper hypo absent normal
o LLQ hyper hypo absent normal
o LUQ hyper hypo absent normal
o RUQ hyper hypo absent normal
Bruits sound aorta renal arteries iliac no bruits sound
c. Percussion
o RLQ resonance hyper-resonance dullness tympani
o LLQ resonance hyper-resonance dullness tympani
o LUQ resonance hyper-resonance dullness tympani
o RUQ resonance hyper-resonance dullness tympani
d. Palpation tenderness unusual lump ____________ _______________
Abdominal superficial reflexes positive negative
Nursing Diagnoses:
Acute/Chronic Pain
Activity Intolerance
Constipation
Diarrhea
_____________________________________________________________________

Senses Left Right
Biceps tendon reflex
Triceps tendon reflex
Brachioradial reflex
normal hypo hyper
normal hypo hyper
normal hypo hyper
normal hypo hyper
normal hypo hyper
normal hypo hyper
7. Lower Extremities
a. Inspection anemia jaundice hyper-pigmented vitiligo cyanosis striae
excoriations Ulcer sikatriks nevi spider nevi hirsutism
ecchymosed alopecia ___________ ____________________
b. Palpation papule vesicle pustule squama crust nodule tumor
fissure sub-cutis emphysema dry skin moist warm
tenderness poor skin turgor _________________ _______________
Edema pitting grade: 0 (no pitting) +1(mild pitting)
+2 (moderate pitting) +3 (deep pitting) +4 (severe pitting)
Femoral Pulses weak strong regular irregular absent
Popliteal pulses weak strong regular irregular absent
Posterior Tibia pulses weak strong regular irregular absent
Dorsalis Pedis pulses weak strong regular irregular absent
c. Percussion




Nursing Diagnoses:
Mobility, Impaired Physical
Activity Intolerance
Skin Integrity, Impaired
Acute or Chronic Pain
Infection, Risk for
Self-care Deficit
Tissue Perfusion, Altered
______________________________________________________________________
8. Genitalia
-Male bulges tenderness hernia scar secretion tumor
varicocele hydrocele inflammation odorous nodule
swelling redness dirty ___________ _______________
-Female inflammation ulcer secretion swelling nodule
cystocele rectocele bulges odorous tenderness
scar redness dirty ____________ _____________ _________

Senses Left Right
Light/Deep Touch
Sharp/dull
Warm/cold
Vibrations
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
positive negative
Senses Left Right
Quadriceps reflex
Achilles tendon reflex
Babinski sign
normal hypo hyper
normal hypo hyper
normal abnormal
normal hypo hyper
normal hypo hyper
normal abnormal
Nursing Diagnoses:
Infection, Risk for
Acute or Chronic Pain
Skin Integrity, Impaired
_________________________________________________________________________________
C. Social Data
Social status single married widow divorced
Social activities organization(s) :_________________________________________________
not involved
Nursing Diagnoses:
Social Interaction, Impaired
Social Isolation
Loneliness, Risk for
Coping, Ineffective
_________________________________________________________________________________
D. Spiritual Data
Worship attendance always often sometimes rare never
Needs priests/friends to pray yes no
Nursing Diagnoses:
Spiritual Distress
Hopelessness
____________________________________________________________________________
E. Psychological Data
Expression sad frowning smiling comfort appearance _________
Emotion anxious afraid angry irritability relax _____________
Coping strategy independent need assistance
Nursing Diagnoses:
Anxiety
Hopelessness
Coping, Ineffective
_________________________________________________________________________________







VII. Diagnostic Tests
No. Kinds of Test Normal Values Patients result Interpretation

Other Tests













IX. Data Analysis
S and O data Etiology Problem







X. Nursing Diagnosis According to Priority
1.
2.
3.
4.