MINDANAO STATE UNIVERSITY

Iligan Institute of Technology

College of Nursing
NURSING HEALTH ASSESSMENT I

Student Name: ________________________ Date of Care: __________Score: ____________

Area of Assignment: _____________________ Clinical Instructor: _______________________
DEMOGRAPHIC DATA
Name: __________________________ Age: ________ Sex: ________ Status: _____________
Address: ________________________ Religion: ___________ Occupation: ________________
HEALTH HISTORY
A. Chief complaint/s:

B. Impression/Admitting Diagnosis:

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation

and alleviation, associated symptoms, previous treatment and result, social and
vocational responsibilities).

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious

disease, immunization/health maintenance, major illness, allergies, medication,
habits, birth and development history, nutrition for pedia)

E. Heath Habits
Kind

Frequency

Amount

Period

1. Tobacco
2. Alcohol
3. OTC drugs
F. Family History with Genogram
History of Heredo-familial diseases:
____ Cancer
____ Diabetes
____ Asthma
Legend:
____ Hypertension
____ Cardiac Disease
____ Mental disorder
____ Others: ______________

Genogram (up to 3rd generation)

G. Patients Perception
Present Illness:

Hospital Environment:

H. Summary of Interaction

PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

NAME: _______________________________________
Vital Signs:
Temperature: _______________
Pulse:
_______________
Respirations: _______________

DATE: __________________________
Height: _______________
Weight: _______________
Blood Pressure:_______________

1. General
2. HEENT

3. Integumentary System
4. Respiratory System
5. Cardiovascular System
6. Digestive System
7. Excretory System
8. Musculoskeletal System
9. Nervous System
10. Endocrine System
11. Reproductive System

NURSING ASSESSMENT II
Name of Patient: _______________________________
Chief Complaints: ______________________________
Impression/Diagnosis: __________________________
Date of Admission: _____________________________
Type of Operation (if any): ___________________________________________

Normal Pattern

Age: ______________ Sex: ________________

Inclusive Dates: __________________________
Allergies: _______________________________
Diet: ___________________________________

Before Hospitalization

Initial

1. Nutrition Metabolic
a. Typical intake (food
or fluid)
b. Diet
c.

Diet restriction

d. Weight
e. Medication /
Supplement food

2. Elimination
a. Urine (frequency,
color, transparency)
b. Bowel (frequency,
color)

Clinical Appraisal
Day 1

Day 2

3. Ego Integrity
a. Perception of self
b. Coping Mechanism
c.

Support Mechanism

d. Mood / Affect

4. Neuro Sensory
a. Mental state
b. Condition of 5
senses (sight,
hearing, smell,
taste, touch)

5. Oxygenation and Vital signs

a. Respiratory rate
b. Pulse rate
c.

Heart rate

d. Blood pressure
e. Lung sounds
f.

History of
respiratory
problems

6. Pain comfort
a. Pain (location,
onset, intensity,
duration, associated
symptoms,
aggravation)
b. Comfort
measure/alleviation
c.

Medication/s

7. Hygiene and activities of

daily living

8. Sexuality
a. Female (menarche,
menstrual cycle,
civil status, number
of children,
reproductive status)
b. Male (circumcision,
civil status, number
of children)

SUMMARY OF MEDICATION
DATE

MEDICATION

DOSAGE

ROUTE

FREQUENCY

REMARKS

SUMMARY OF INTRAVENOUS FLUID

DATE

IV FLUID & VOLUME

DROP RATE

TIME STARTED

TIME ENDED

INDICATION

DIAGNOSTIC AND LABORATORY PROCEDURE/S

PROCEDURE

INDICATION

NORMAL VALUE

RESULT

IMPLICATION

NURSING
RESPONSIBILITIES

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

10

DRUG STUDY
MEDICATION
(include dosage,
route & frequency)

DRUG
CLASSIFICATION

INDICATION

MECHANISM OF
ACTION

11

SIDE
EFFECTS/ADVER
SE REACTIONS

NURSING
RESPONSIBILITIE
S

CONTRAINDICATI
ONS AND
CAUTIONS

NURSING CARE PLAN

Identified Problem:
Nursing Diagnosis:
CUES
Objective cues:

OBJECTIVES
Short term objective:

Subjective cues:

Long term objective:

INTERVENTIONS

12

RATIONALE

EVALUATION

DISCHARGE PLAN
DRUG

DOSAGE

FREQUENCY

Medication

Exercise

Therapy

Health Teachings

OPD Visit

Diet

Spiritual

13

ROUTE

INDICATION

MEDICAL/SURGICAL MANAGEMENT
(IDEAL AND ACTUAL)
IDEAL

ACTUAL

14

NURSING MANAGEMENT
(IDEAL AND ACTUAL)
IDEAL

ACTUAL

15

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