Western Mindanao State University College of Nursing Zamboanga City Format of Nursing Process I. Assessment A.

Personal Data Name: Address: Age: Sex: Status: Occupation: Educational Attainment: Ethnic Origin: Dialect/Language spoken: Religion: Chief complaint: Medical impression: B. Nursing history (11 functional health patterns) 1. Health Perception – Health Management pattern a. How was your general health been? Past illness? Present illness? Family health status? b. What cause your illness? c. What have you done to solve your problems? d. Was the action effective? e. Most important things done to keep healthy [ include family folk if appropriate] f. Immunization status [if appropriate] 2. Nutritional – Metabolic Pattern a. Typical daily food intake? [Describe] food supplements? b. Typical daily fluid intake [describe] time? c. Weight loss? Gain? [amount] d. Foods or eating discomforts? Diet restriction? Religious beliefs? e. Skin problems, lesions and dryness? General ability to heal? f. Dental problems? Height? g. Food preferences, use of nutrients or vitamin supplement? 3. Elimination Pattern a. Bowel elimination pattern [describe] frequency? Discomfort? Character? b. Urinary elimination pattern [describe] frequency? Discomfort? Character? c. Excess perspiration? Odor problems? d. Any discharges? [wound] e. Any devise employed to control excretion? f. Use of laxatives or aid for bowel elimination? 4. Activity – Exercise Pattern a. Sufficient energy for completing desired/required activities? b. Exercise pattern? Type? Regularity? c. Spare time [leisure] activities? Child play activities?

d. Perceive ability for: [code for level] Feeding ____ Dressing ____ Cooking ____ Bathing ____ Grooming ____Toileting ____ Home Maintenance ____ Shopping ____ General Mobility ____ Bed Mobility ____ Functional Level Code: Level 0: full self-care Level 1: requires use of equipment or device Level 2: requires assistance or supervision from another person Level 3: requires assistance or supervision from another person and equipment Level 4: is independent and does not participate 5. Sleep – Rest pattern a. How many hours of sleep/rest per day? b. Generally rested and ready for daily activities after sleep? c. Sleep onset problems? [Nightmares? somnambulism? early awakening?] d. Time of sleep? Awakening? e. Aids to sleep such as medication or night time routine that the individual employs? 6. Cognitive – perceptual Pattern a. Hearing difficulty? [include hearing aid and if there is any] b. Visions? [Eyeglasses? Contact lenses? Allergies?] c. Any changes in the memory lately d. Any difficulty in hearing? e. Any discomforts? Pain? How do you manage it? 7. Self-perception – self-concept pattern a. How do you describe yourself? Moods/ perception towards self? b. Changes in the body or things you can do? c. Change sin the way you feel about yourself or your body? [ since illness started] d. Things that frequently make you angry? [depressed? Anxious? What helps?] e. Are you happy/contented about yourself? 8. Role-Relationship Pattern a. Family structure? How many members in the family? [How do you describe the interpersonal relationship among family members?] Language spoken? b. Live alone? Family type? c. How does the family usually handle problems? d. Who is the breadwinner? e. Problems with children? Difficulty handling? f. How family feels [or others] about your illness? g. Belongs to social groups? Close friends? Feel lonely [frequency]

h. Do things generally go well with you at work [school/college] i. If appropriate, include family income. Is the income sufficient for the needs? j. Feel part of or isolated neighborhood where residing? 9. Sexuality – Reproductive Pattern a. How may children? History of abortions? Stillbirths? Premature? b. Any change or problems in sexual relationship? c. Use of contraceptives? Problems? d. Females: when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? e. Describe client to the 3 major component of sexuality: =reproductive sexuality = gender sexuality = erotic sexuality 10. Coping – Stress Tolerance Pattern a. How does the family cope in times of crisis? b. Tense a lot of time? What helps? Use of any medicines/drugs? c. Any big changes in your life in the last year or two? d. When you have a big problem, how do you handle theme? Successful in handling problems? 11. Health – Belief Pattern a. What do you consider as the most valuable/ important in life? b. Generally get things you like? Most important things? c. Is religion important to your life? Does this help you when a difficulty arises? d. Does illness/hospitalization interferes with any religious practice? 12. Others: a. Any things we have talked about that you’d like to mention? b. Questions? 13. Growth/Development Milestone a. Theories: Erik Erikson, Sigmund Freud, Jean Piaget b. Gross motor skills c. Fine motor skills d. Play/socialization Actual observation (or as related by the SO) II. Physical Examination Head: shape, hair, scalp Face: a. eyes b. ears c. nose d. oral cavity e. other parts of the face (forehead, cheeks, and chin) Neck: throat and nape Chest and Breast: Document readings and resources

Back: Abdomen: Upper and Lower extremities: Genitalia: a. Physiologic examination 1. central nervous system • Level of awareness • Attention deficit • Communication [verbal and non-verbal] • Coordination [ use of fingers in picking up pencils] 2. special senses • auditory perception • pupillary perception • speech perception • gustatory perception • visual perception • tactile perception • olfactory perception 3. respiratory system – rate, rhythm, depth, breath sound 4. cardiovascular system – rate, rhythm, blood pressure 5. nutritional status – skin, mucus membranes, nails, height, weight, body temperature 6. elimination status – color, amount, frequency, consistency, odor of urine and stool and perspiration 7. motor ability status – gait, posture, body movements III. Laboratory and diagnostic test results 1. blood studies ( CBC, hematocrit, hemoglobin, fast blood sugar, blood urea) 2. urinalysis 3. fecalysis 4. sputum 5. gastrointestinal series 6. x-rays 7. ECG/EKG 8. others IV. Drug study • Brand name • Generic name • Classification • Dosage and frequency, route of administration • Side effects and adverse reactions • Nursing responsibilities

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