You are on page 1of 5

COLLEGE OF NURSING Xavier University Ateneo de Cagayan LEVEL IV NURSING HISTORY AND ASSESSMENT RECORD I.

PATIENT’S PROFILE Name of patient: Age: Religion: Date and time of admission: Language/dialect spoken: Informant: Temperature: O2 sat: Pulse: Height: Civil Status:

Diagnosis: Attending physician:

Respiration: Weight:

BP:

Chief complaint/ reason for hospitalization:

History of present illness:

Family Medical History: ( ) Heart disease ( ) Lung disease ( ) Hypertension(both parents and patient) ( ) Stroke ( ) Others: ( ) Cancer

( ) Substance Abuse ( ) Renal disease

D=Dependent) ( ) Eating ( ) Bathing ( ) Dressing ( ) Grooming ( ) Toileting ( ) Ambulating Activity Level: ( ) Active ( ) Sedentary Comments/Nursing problems identified: E.II.5-24. NUTRITION/METABOLLIC PATTERN Meal Pattern: Appetite: ( ) Good ( ) Fair ( ) Poor Changes in eating habit: ( ) Yes ( ) No Appetite changes: ( ) Yes ( ) No Weight loss/gain: Special diet: Comments/ Nursing problems identified: BMI ( kg/m² )= (weight in pounds * 703) = height in inches² BMI score range: Underweight = <18. ACTIVITY/ EXERCISE Activities of Daily Living ( I= Independent.9 Overweight = 25-29. SLEEP/REST PATTERN ( ) No difficulty ( ) Yes (describe) Use of sleeping aids: ( ) Yes Comments/ Nursing problems identified: ( ) No D. A=w/ Assistance.5 Normal weight = 18.9 Obesity = BMI of 30 or greater Comments/ Nursing problems identified: B. FUNCTIONAL PATTERN A. ELIMINATION PATTERN Bladder : ( ) No difficulty ( ) Dysuria ( ) Oliguria ( ) Incontinence ( ) Nocturia ( ) Anuria ( ) UTI ( ) Stones ( )On catheter Comments/Nursing problems identified: Bowel: COlostomy ( ) No difficulty ( ) Constipation ( ) ( ) Incontinence ( ) Ileostomy Comments/ Nursing problems identified: C. COGNITIVE PERCEPTION PATTERN .

ROLE RELATIONSHIP PATTERN Occupation: With whom does patient live: Anticipating to return home: ( ) Yes ( ) No: Persons available to assist at home: Comments/Nursing problems identified: III.) A. NEUROLOGICAL ASSESSMENT SUBJECTIVE and objective cues for OBJECTIVE .Glasses: ( ) Yes ( ) No Hearing Aids: ( ) Yes [ ] right [ ] left ( ) No ( ) No Contact Lens: ( ) Yes [ ] right [ ] left Prosthesis: ( ) Yes ( )No [ ] right [ ]left Comments/Nursing problems identified: F. BEHAVIOR PATTERN (COPING/ VALUES) Behavior: ( ) Relaxed ( ) Mildly Anxious ( ) Moderately Anxious ( ) Very Anxious Psychiatric History:" SUBSTANCE ABUSE: Tobacco ( ) Yes (X) No Drugs ( ) Yes (X) No Alcohol ( ) Yes (X) No Cigarrete/Cigar/pipe ( ) Yes (X) No Comments/Nursing problems identified: G. # of weeks Breast (cyst/lump/discharge): ( ) No ( ) Yes Testicular/prostate problem: ( ) No ( ) Yes Birth Control: ( ) NA ( ) No ( ) Yes (describe) Comments/Nursing problems identified: I. PAIN ( ) None ( ) Present (describe) Present pain management: Comments/Nursing problems identified: H. SEXUALITY/ REPRODUCTION HEALTH Date of last Pap Smear: Is Patient pregnant? ( ) No ( ) Unsure ( ) Yes. PHYSICAL ASSESSMENT (Indicate subjective abnormalities noted.

Heart rate 60-100 bpm. RESPIRATORY ASSESSMENT Resp. place and time Pupils equally round & reactive to light Paresthesia (weakness) or paralysis of extremities __________ No difficulty of speech and swallowing noted ________ B. PERIPHERAL-VASCULAR ASSESSMENT Extremities pink. No muscle Weakness. warm & movable w/in normal ROM Peripheral pulses palpable No edema No complaints of numbness/ calf tenderness E.Alert and oriented to person. no evidence of inflammation. No complaints of chest pain and edema D. No complaints of back pain . frequency w/in own pattern No unusual vaginal or penile discharges/ irritation noted F. Normal ROM of all joints. GENITOURINARY ASSESSMENT Voiding without discomfort or difficulty Urine clear. MUSCULOSKELETAL ASSESSMENT Absence of joint swelling & tendernesss. 12-22 cpm at rest Respirations quiet and regular Breath sounds in both lung fields clear Nail beds and lips pink C. CARDIOVASCULAR ASSESSMENT Regular apical pulse.

( ) Yes ( ) No___________________ 10. ( ) Yes ( ) No___________________ 9. dry. ( ) Yes ( ) No___________________ 5. ( ) Yes ( ) No___________________ 8. ( ) Yes ( ) No___________________ 3.INTEGUMENTARY ASSESSMENT Skin color w/in patient’s norm Skin warm. ( ) Yes ( ) No___________________ Comments/Nursing problems identified: PRIORITY NURSING DIAGNOSIS IDENTIFIED: 1 2 3 4 5 . 1. ( ) Yes ( ) No___________________ 7. ( ) Yes ( ) No___________________ 2. ( ) Yes ( ) No___________________ 6. provide comments. ( ) Yes ( ) No___________________ 4. intact Decubitus/ buirns present? ( ) yes ( ) no Skin/Burns CURRENT MEDICATIONS : Does the client have correct knowledge of the medications taken? If no.G.