Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student _____________________________________ Area of Assignment Clinical Instructor

____________________________________ Date Submitted _____________________________________ NURSING ASSESSMENT I PATIENTS PROFILE Name Sex Religion Address Civil Status Occupation Age

HEALTH HABITS Frequency 1. Tobacco 2. Alcohol 3. OTC-drugs/ non-prescription drugs Amount Period/Duration

A. CHIEF COMPLAINTS

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

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

FAMILY HISTORY WITH GENOGRAM Acquired Diseases: Hypercholesterolemia Kidney Disease Tuberculosis Alcoholism Drug Addiction Hepatitis A B C Others (pls. specify) Heredo- familial Diseases: Diabetes Heart Diseases Hypertension Cancer Asthma Epilepsy Mental Illness Rheuma/Arthritis Others (pls. specify)

D. PATIENTS PERCEPTION OF: 1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION

REVIEW OF SYSTEMS Name Vital Signs: Temperature Pulse Respiration Blood Pressure Date Height Weight Observation ____________________________________

1.GENERAL

2. HEENT

3. INTEGUMENTARY

4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10. ENDOCRINE

DRUG STUDY

BRAND NAME GENERIC NAME CLASSIFICATION

Prescribed and Recommended dosage, frequency, route of administration

Mechanism Of Action

Indication

Contraindication

Adverse Reaction

Nursing Responsibilities

NURSING ASSESSMENT II

Name Chief Complaint Impression/Diagnosis Date/Time of Admission _ Allergies __________

Age _________________________________ _____________ Diet: _______ __

____

Sex

____

Inclusive Dates of Care _ _____________________ Type of Operation (if any)

NORMAL PATTERN

BEFORE HOSPITALIZATION

INITIAL DAY 1

CLINICAL APPRAISAL DAY 2

1.ACTIVITIES- REST a. Activities b. Rest c. Sleeping pattern

2.NUTRITIONALMETABOLIC a. Typical intake(food, fluid) b. Diet c. Diet restrictions d. Weight e. Medications/suppleme

nt

food

3. ELIMINATION a. Urine (frequency, color, transparency) b. Bowel (frequency, color, consistency) 4. EGO INTEGRITY a. Perception of self b. Coping Mechanism c. Support System d. Mood/Affect

5. NEURO-SENSORY a. Mental state .

b. Condition of five senses: (sight, hearing, smell, taste, touch)

6. OXYGENATION a. Vital signs Temperature Respiratory rate Heart rate Blood pressure b. Lung sounds c. History of Respiratory Problems

7. PAIN-COMFORT a. Pain (location, onset, character, intensity, duration, associated symptoms, aggravation) b. Comfort measures/Alleviation c. Medications

8. HYGIENE AND ACTIVITIES OF DAILY LIVING

9. SEXUALITY a. female (menarche, menstrual cycle, civil status, number of children, reproductive status) b. male (circumcision, civil status, number of children)

LABORATORY AND DIAGNOSTIC PROCEDURES DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

SUMMARY OF INTRAVENOUS FLUID DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

SUMMARY OF MEDICATION

DATE

MEDICATIONS- dosage, frequency, route

Remarks

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

NURSING MANAGEMENT

SURGICAL MANAGEMENT

DISCHARGE PLAN NAME ______________________________________________ CONDITION UPON DISCHARGE against medical advice ( ) ___________ DATE OF DISCHARGE: ____________________ Nature: Home per request ( ) Discharge

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION