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Mindanao State UniversityCOLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student_____________________________________ Cini!a Instru!tor_________________________________

Area of Assi"nment___________________________________ #ate Su$mitted___________________________________

NU%SING ASSESSMENT I

&ATIENT'S &%OFILE

Name_______________________________________ Address__________________________________________________________ A"e_______

Se(_________ %ei"ion________________________ Civi Status______________________

O!!u)ation________________________

HEALTH HA*ITS

Fre+uen!y Amount &eriod,#uration

-. To$a!!o _______________ _____________ _____________/. A!o0o _______________ _____________ _____________1. OTC2dru"s, non2)res!ri)tion dru"s _______________ _____________ _____________

A. CHIEF COM&LAINTS

*. HISTO%3 OF &%ESENT ILLNESS 4H&I5 6o!ation7 onset7 !0ara!ter7 intensity7 duration7 a""ravation7 and aeviation7 asso!iated

sym)toms7 )revious treatment and resuts7 so!ia and vo!ationa res)onsi$iities7 a8e!ted dia"noses9.


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C. HISTO%3 OF &AST ILLNESS 4)revious 0os)itai:ation7 in;uries7 )ro!edures7 infe!tious disease7 immuni:ation,0eat0 maintenan!e7

ma;or inesses7 aer"ies7 medi!ations7 0a$its7 $irt0 and deveo)menta 0istory7 nutrition2for pedia5

FAMIL3 HISTO%3 idney #iseases _______ Heart #iseases ______Tu$er!uosis _______ Hy)ertension ______A!o0oism _______ Can!er ______#ru" Addi!tion _______ Ast0ma ______He)atitis A _______ E)ie)sy

______* _______ Menta Iness ______C _______ %0euma,Art0ritis ______

Ot0ers 4)s. s)e!ify5 _______ ot0ers 4)s. s)e!ify5 ______

#. &ATIENT'S &E%CE&TION OF=

-. &resent Iness ?

/. Hos)ita Environment ?

E. SUMMA%3 OF INTE%ACTION


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%E@IE< OF S3STEMS

Name_____________________________ #ate________________@ita Si"ns= Hei"0t_______________

Tem)erature_________


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1. INTEGUMENT

A%3

-. %ES&I%ATO%3

/. CA%#IO@ASCUL

A%

1. #IGESTI@E

. EBC%ETO%3

. MUSCULOS>ELE

TAL

D. NE%@OUS

. EN#OC%INE


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#%UG STU#3

*%AN# NAME

GENE%IC NAME

CLASSIFICATION

&res!ri$ed

dosa"e7

fre+uen!y7 route

of administration

Me!0anism

Of

A!tion

Indi!ation Contraindi!ation Adverse %ea!tionNursin"

%es)onsi$ii


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NU%SING ASSESSMENT II

Name___________________________________________________________ A"e______ Se(_______

C0ief Com)aint___________________________________________________

Im)ression,#ia"nosis______________________________________________

#ate,Time of Admission____________________________________________ In!usive #ates of Care _______________

#iet_____________________________________________________________ Aer"ies___________________________

Ty)e of O)eration 4if any5___________________________________________

NO%MAL &ATTE%N*EFO%E

HOS&ITALIATIONINITIAL

CLINICAL A&&%AISAL

#A3 - #A3 /

-. ACTI@ITIES ? %EST

a. A!tivities

$. %est

!. See)in" &attern

/. NUT%ITIONAL

META*OLIC

a. Ty)i!a intae4food7

uid5

$. #iet

!. #iet restri!tions

d.


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ent food

1. ELIMINATION

a. Urine 4fre+uen!y7

!oor7 trans)aren!y5

$. *owe 4fre+uen!y7

!oor7 trans)aren!y5

. EGO INTEG%IT3

a. &er!e)tion of sef

$. Co)in" Me!0anism

!. Su))ort System

d. Mood,A8e!t


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. NEU%O2SENSO%3

a. Menta state

$. Condition of ve

senses= 4i"0t7

0earin" sme7taste7 tou!05

D. OB3GENATIONa. @ita si"ns

Tem)erature%es)iratory rateHeart rate*ood &ressure

$. Lun" sounds!. History of

%es)iratory

&ro$ems


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. &AIN2COMFO%Ta. &ain 4o!ation7

onset7 !0ara!ter7

intensity7 duration7asso!iated

sym)toms7

a""ravation5

$. Comfort measures,

Aeviation

!. Medi!ations

J. H3GIENE AN#ACTI@ITIESOF #AIL3 LI@ING


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K. SEBUALIT3

a. femae 4menar!0e7

menstrua !y!e7 !ivi

status7 num$er of

!0idren7

re)rodu!tive status5

$. mae 4!ir!um!ision7

!ivi status7 num$er

of !0idren5


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LA*O%ATO%3 AN# #IAGNOSTIC &%OCE#U%ES

#ATE NAME OF THE &%OCE#U%E %ESULT NO%MAL @ALUE NU%SING IM&LICATION


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SUMMA%3 OF INT%A@ENOUS FLUI#

#ATE,TIME STATE# INT%A@ENOUS FLUI# AN# @OLUME #%O& #ATENUM*E% OF

HOU%S

#ATE,TIME

CONSUME#


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SUMMA%3 OF ME#ICATION

#ATE ME#ICATIONS2 dosa"e7 fre+uen!y7 route %emars


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ANATOM3 AN# &H3SIOLOG3


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&ATHO&H3SIOLOG3


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ME#ICAL MANAGEMENT


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NU%SING MANAGEMENT


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SU%GICAL MANAGEMENT


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#ISCHA%GE &LAN

NAME_______________________________________________ #ATE OF #ISCHA%GE___________________________

CON#ITION U&ON #ISCHA%GE_________________________________ Nature= Home )er re+uest 4 5 #is!0ar"e a"ainst medi!a advi!e 4

-. ME#ICATIONS

/. EBE%CISE

1. #IET

. HEALTH TEACHING

. SCHE#ULE FO% THE NEBT @ISIT


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NU%SING CA%E &LAN

CUES NU%SING #IAGNOSIS O*ECTI@ES INTE%@ENTIONS %ATIONALE E@ALUATION

NU%SING CA%E &LAN


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NU%SING CA%E &LAN


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