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


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


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)




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 =


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