Revised 2019

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: _____________________________________ Clinical Instructor: ________________________________

Area of Assignment: ___________________________________ Date Submitted: _________________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name: _______________________________________ Address: ___________________________________________________________________ Age: ________

Sex: _________ Religion: __________________ Civil Status: ___________________________ Occupation: ___________________________________

HABITS

Frequency Amount Period/Duration

1. Tobacco
2. Alcohol
3. OTC-drugs/ non-prescription drugs

A. CHIEF COMPLAINTS:

B. HISTORY OF PRESENT ILLNESS (HPI) {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 Disease Heart Diseases
Tuberculosis Hypertension
Alcoholism Cancer
Drug Addiction Asthma
Hepatitis A Epilepsy
B Mental Illness
C Rheuma/Arthritis
Others (pls. specify) Others (pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION
 Physical Examination

Name: ____________________________________ Date: ______________

Chief Complaint upon Initial Assessment: _______________________________________ Height: _____________
Chief Complaint upon Final Assessment: ________________________________________ Weight: _____________
Initial Vital Signs: Temp: ______ RR: ______ PR: ______ O2Sat: ______ BP: ________ Pain Score: ________ BMI: _______________
Initial Assessment Final Assessment (Last Day)

GENERAL

HEENT

INTEGUMENTARY
RESPIRATORY

CARDIOVASCULAR

DIGESTIVE

EXCRETORY

MUSCULOSKELETAL
NERVOUS

ENDOCRINE
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
 NURSING ASSESSMENT II

Name Age Sex ________

Admitting Chief Complaint
Impression/Diagnosis _____________
Date/Time of Admission Inclusive Dates of Care _ _
Diet: _____________________ Allergies _______ __
Type of Operation (if any) __________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

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/supplement
food
3. ELIMINATION

a. Urine (frequency, color,

transparency)

b. Bowel (frequency, color,

consistency)

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:

(sight, 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 STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE 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 ( ) Discharge against medical advice ( )

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION