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Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student_____________________________________ Clinical Instructor_________________________________

Area of Assignment___________________________________ Date Submitted___________________________________

NURSING ASSESSMENT I

PATIENTS PROFILE

Name_______________________________________ Address__________________________________________________________ Age_______

Sex_________ Religion________________________ Civil Status______________________ Occupation________________________

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco _______________ _____________ _____________2. Alcohol _______________ _____________ _____________3. OTC-drugs/ non-prescription drugs _______________ _____________ _____________

A. CHIEF COMPLAINTS

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social andvocational responsibilities, affected diagnoses}.

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C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, band developmental history, nutrition-for pedia)

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia _______ Diabetes ______

Kidney Diseases _______ Heart Diseases ______

Tuberculosis _______ Hypertension ______

Alcoholism _______ Cancer ______

Drug Addiction _______ Asthma ______

Hepatitis A _______ Epilepsy ______

B _______ Mental Illness ______

C _______ Rheuma/Arthritis ______

Others (pls. specify) _______ others (pls. specify) ______

D. PATIENTS PERCEPTION OF:1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION

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REVIEW OF SYSTEMS

Name_____________________________ Date________________

Vital Signs: Height_______________

Temperature_________ Weight______________

Pulse________ Observation_______________________________________________________________

Respiration___________ _________________________________________________________________________

Blood Pressure________ __________________________________________________________________________

1. GENERAL

2. HEENT

3. INTEGUMENTARY

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4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10.ENDOCRINE

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DRUG STUDY

BRAND NAME GENERIC

NAME CLASSIFICATION

Prescribed dosage,

frequency, route of

administration

Mechanism

Of

Action

Indication Contraindication Adverse Reaction Nursing Responsi

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NURSING ASSESSMENT II

Name___________________________________________________________ Age______ Sex_______

Chief Complaint___________________________________________________

Impression/Diagnosis______________________________________________

Date/Time of Admission____________________________________________ Inclusive Dates of Care ___________________

Diet_____________________________________________________________ Allergies___________________________

Type of Operation (if any)___________________________________________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIALCLINICAL APPRAISAL

DAY 1 DAY 2

1. ACTIVITIESRESTa. Activitiesb.

Rest

c. Sleeping Pattern

2. NUTRITIONAL METABOLICa. Typical intake(food, fluid)b. Dietc. Diet restrictionsd. Weighte. Medications/supplement

food

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3. ELIMINATIONa. Urine (frequency, color,

transparency)

b. Bowel (frequency, color,transparency)

4. EGO INTEGRITYa. Perception of selfb. Coping Mechanismc. Support Systemd. Mood/Affect

5. NEURO-SENSORYa. Mental state

b. Condition of five senses:(light, hearing smell, taste,

touch)

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6. OXYGENATIONa. Vital signs

Temperature

Respiratory rate

Heart rate

Blood Pressure

b. Lung soundsc. History of Respiratory

Problems

7. PAIN-COMFORTa. Pain (location, onset,

character, intensity,

duration,

associated symptoms,

aggravation)

b. Comfort measures/Alleviation

c. Medications

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8. HYGIENE AND ACTIVITIESOF DAILY LIVING

9. SEXUALITYa.female (menarche, menstrual

cycle, civil status, number of

children, reproductive status)

b.male (circumcision, civilstatus, number of children)

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LABORATORY AND DIAGNOSTIC PROCEDURES

DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

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SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STATED INTRAVENOUS FLUID AND VOLUME DROP DATE NUMBER OF HOURS DATE/TIME CONSUMED

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SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks

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ANATOMY AND PHYSIOLOGY

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PATHOPHYSIOLOGY

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MEDICAL MANAGEMENT

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NURSING MANAGEMENT

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SURGICAL MANAGEMENT

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DISCHARGE PLAN

NAME_______________________________________________ DATE OF DISCHARGE___________________________

CONDITION UPON DISCHARGE_________________________________ Nature: Home per request ( ) Discharge against medical advice ( )

1.MEDICATIONS

2.EXERCISE

3.DIET

4.HEALTH TEACHING

5.SCHEDULE FOR THE NEXT VISIT

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NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

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NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

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NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION