Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student_____________________________________ Clinical Instructor_________________________________

Area of Assignment___________________________________
PATIENT’S PROFILE
Name_______________________________________
Sex_________ Religion________________________
Date Submitted___________________________________
NURSING ASSESSMENT I
Address__________________________________________________________ Age_______
Civil Status______________________ Occupation________________________

HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco _______________ _____________ _____________
2. Alcohol _______________ _____________ _____________
3. OTC-drugs/ non-prescription drugs _______________ _____________ _____________

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 _______ 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
 REVIEW OF SYSTEMS

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

1. GENERAL

2. HEENT

3. INTEGUMENTARY
1. RESPIRATORY

2. CARDIOVASCULAR

3. DIGESTIVE

4. EXCRETORY

5. MUSCULOSKELETAL

6. NERVOUS

7. ENDOCRINE
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

BRAND NAME GENERIC
frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities
NAME CLASSIFICATION
administration Action
 DRUG STUDY

Prescribed dosage, Mechanism

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

Name___________________________________________________________ Age______ Sex_______

Chief Complaint___________________________________________________
Impression/Diagnosis______________________________________________
Date/Time of Admission____________________________________________ Inclusive Dates of Care ___________________
Diet_____________________________________________________________ Allergies___________________________
Type of Operation (if any)___________________________________________

CLINICAL APPRAISAL
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL
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,

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
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
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