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Adult Nursing Process Guide

This document provides a guide for conducting an adult nursing process, including sections on collecting vital information, performing a clinical assessment, and documenting nursing progress notes. The clinical assessment involves gathering information on nursing history, past health problems, family history, patient expectations, patterns of functioning, clinical inspection of vital signs, and a psychosocial nursing assessment. Data is collected on topics like medical history, lifestyle, personality, and a mental status exam. Nurses use this guide to systematically assess patients and document findings.

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Mark Arconada
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226 views9 pages

Adult Nursing Process Guide

This document provides a guide for conducting an adult nursing process, including sections on collecting vital information, performing a clinical assessment, and documenting nursing progress notes. The clinical assessment involves gathering information on nursing history, past health problems, family history, patient expectations, patterns of functioning, clinical inspection of vital signs, and a psychosocial nursing assessment. Data is collected on topics like medical history, lifestyle, personality, and a mental status exam. Nurses use this guide to systematically assess patients and document findings.

Uploaded by

Mark Arconada
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City

ADULT NURSING PROCESS GUIDE

I. VITAL INFORMATION Name: Age: Sex: Address: Civil Status: Date and Time Admitted: Chief Complaint: Ward: Bed No.: Allergies: Religious Affiliation: Physicians Initial: Impression/Diagnosis: Pre-op Diagnosis: Post-op Diagnosis: Surgical Operation Performed: Days of Post-op: Date of Interview: Informant: Relationship to Patient:

II. CLINICAL ASSESSMENT II. A.: NURSING HISTORY 1.History of Present Illness a. Usual Health Status

b. Chronologic Story

b.Relevant Family History

c. Disability Assessment

2. Past Health Problems/Status a. Childhood Illness

b.Immunizations

c. Allergies

d. Accidents and Injuries

e. Hospitalizations for serious illnesses

f. Medications

3. Family History of Illness

4.Patients Expectations a. What does he/she expect to occur during hospitalization?

b. What does he/she expect regarding nursing care?

5. Patterns of Functioning a. Breathing Patterns Respiratory Problems: Usual Remedy: Manner of Breathing: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.

c. Sleep Patterns Usual bedtime: Number of pillows: Bedtime Rituals: Problems regarding sleep: Usual remedy: d. Drinking Patterns Kinds in Fluid in 24 hours/ Amount in mL or Number of Bottles: Kind of Fluid Amount

e. Eating Patterns Usual Food Taken (quantify) Breakfast Time (range)

Lunch

Dinner

Snacks

Food Likes: Food Dislikes:

f. Elimination Patterns 1.Bowel Movement Frequency: Problems or Difficulties: Usual Remedy:

2.Urination Frequency: Problems: Usual Remedy: g. Exercise:

h. Personal Hygiene 1.Bath Type: Frequency: Time of Day: 2.Oral Care Frequency: Care of Dentures: 3.Shaving: Frequency: 4.Use of Cosmetics:

i. Recreation:

j. Health Supervision:

II. B.: CLINICAL INSPECTION II.B.1. Vital Signs: T= BP = II.B.2 Height: II.B.3.Weight: Date and Time taken: PR = RR =

II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT 1. Lifestyle information

2. Normal coping patterns

3. Understanding of present illness

4. Personality Style:

5. History of Psychiatric Disorder:

6. Recent Life Changes or Stressors:

7. Major Issues Raised by Current Illness:

8. Mental Status Examination (Circle the correct words. Include a short description of client for each area assessed.) APPEARANCE Neat Clean Dishevelled inappropriate makeup Poor Grooming Erect Posture

Good eye contact Description:

Others: ___________________

BEHAVIOR Calm Appropriate Restless Agitated Compulsions

Unusual actions Description:

Others: __________________

SPEECH Appropriate Mute Description: Pressured Loose Association Loud Soft

Others: ________________________

MOOD/AFFECT Appropriate Angry Description: Labile Hopeless Flat Depressed Worried Anxious

Others: _________________

THOUGHTS Appropriate Delusions Description: Low Phobias Self-Esteem Suicidal Ideations Hallucinations

Others: ______________________

ABILITY TO ABSTRACT Impaired: Description: YES NO

MEMORY Impaired recent memory: Impaired past memory: YES YES NO NO

Number of objects able to remember after 5 minutes: Description:

ESTIMATED INTELLIGENCE Below Average Average Above Average

CONCENTRATION Able to Focus Easily distractible

Able to subtract backwards by 7s from 100 correctly until number _______________.

ORIENTATION Person ______ Time _______ Place _______ Situation _______

JUDGEMENT Realistic decision making: Description: YES NO

INSIGHT Good Description: Fair Poor

II.C. NURSING PROGRESS NOTES (On-going Appraisal)

P/I

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