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Mindanao State University

COLLEGE OF HEALTH SCIENCES


Marawi City
Name of Student_____________________________________

Clinical Instructor_________________________________

Area of Assignment___________________________________

Date Submitted___________________________________
NURSING ASSESSMENT I

PATIENTS PROFILE
Name_______________________________________

Address__________________________________________________________

Sex_________
Religion________________________
Occupation________________________

Age_______

Civil Status______________________

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:
Heredo- familial Diseases:
Hypercholesterolemia _______
Diabetes
______
Kidney Diseases
_______
Heart Diseases
______
Tuberculosis
_______
Hypertension
______
Alcoholism
_______
Cancer
______
Drug Addiction
_______
Asthma
______
Hepatitis
A
_______
Epilepsy
______
B
_______
C
_______
Others (pls. specify) _______
D. PATIENTS PERCEPTION OF:
1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION

Mental Illness
______
Rheuma/Arthritis ______
others (pls. specify)
______

REVIEW OF SYSTEMS
Name_____________________________
Date________________
Vital Signs:
Height_______________
Temperature_________
Weight______________
Pulse________
Observation____________________________________________________________________
Respiration__________
______________________________________________________________________________
Blood Pressure__________
______________________________________________________________________________

1. GENERAL

2. HEENT

3. INTEGUMENT
ARY

1. RESPIRATORY

2. CARDIOVASCUL
AR

3. DIGESTIVE

4. EXCRETORY

5. MUSCULOSKELE
TAL

6. NERVOUS

7. ENDOCRINE

DRUG STUDY
BRAND NAME
GENERIC NAME
CLASSIFICATION

Prescribed
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____________________________________________
Diet_____________________________________________________________
Type of Operation (if any)___________________________________________

NORMAL PATTERN

1. ACTIVITIES REST
a. Activities
b. Rest
c. Sleeping Pattern
2. NUTRITIONAL
METABOLIC
a. Typical intake(food,
fluid)
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplem

BEFORE
HOSPITALIZATION

Age______

Sex_______

Inclusive Dates of Care ___________________


Allergies___________________________

CLINICAL APPRAISAL

INITIAL
DAY 1

DAY 2

ent food

3. ELIMINATION
a. Urine (frequency,
color, transparency)
b. Bowel (frequency,
color, transparency)

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: (light,
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 STATED

INTRAVENOUS FLUID AND VOLUME

DROP DATE

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_______________________________________________

DATE OF DISCHARGE___________________________

CONDITION UPON DISCHARGE_________________________________

Nature: Home per request ( )

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

Discharge against medical advice ( )

NURSING CARE PLAN


CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

NURSING CARE PLAN

RATIONALE

EVALUATION

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

NURSING CARE PLAN

RATIONALE

EVALUATION

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION