ST.

ANTHONY’S COLLEGE
Nursing Department
San Jose, Antique

• NURSING PROCESS •
(Emergency Nursing)

I. VITAL INFORMATION
Name: Date of Interview:
Age: Informant:
Address: Relationship to Patient:
Civil Status:
Date and Time Admitted:
Chief Complaint:

Allergies:
Religious Affiliation:
Physician’s Initial:
Impression/Diagnosis:

II. CLINICAL ASSESSMENT

A. NURSING HISTORY
1. History of Present Illness
a. Usual Health Status

b. Chronologic Story
2. Past Health Problems/Status

3. Family History of Illness

III. PRIMARY SURVEY

Airway:

Breathing:

Circulation:

Disability:

Farenheit:

Get Vital Signs:

T= PR=
BP= RR=

History:
Last Medication:

Last Meal:
IV. SECONDARY SURVEY

Date and Time Taken:

1. Vital signs:
T= PR=
BP= RR=

2. Height:

3. Weight:

4. PHYSICAL ASSESSMENT

A. INTEGUMENTARY SYSTEM

B. NEUROLOGIC/EENT:

C. RESPIRATORY SYSTEM:
D. CARDIOVASCULAR/CIRCULATORY SYSTEM:

E. GASTROINTESTINAL SYSTEM:

F. GENITO-URINARY SYSTEM:

G. REPRODUCTIVE SYSTEM:

H. ENDOCRINE SYSTEM:

I. MUSCULOSKELETAL SYSTEM:
J. LYMPHATIC SYSTEM:

K. HEMATOPOIETIC SYSTEM:
 II.C.B. NURSING PROGRESS NOTES (Ongoing Appraisal)

Date & Time:

P/I

E( )

Date & Time:

P/I

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Date & Time:

P/I

E( )

Date & Time:

P/I

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