Nursing Process

Critical Care Unit

Date of Interview: Informant:

Relationship to the client:

I. Biographical Data

Name:

Address:

Contact person:

Age/Birth Date:

Place of Birth:

Gender:

Race/Ethnicity/Nationality:

Religion:

Marital Status:

Educational Level:

Occupation:

Referral:

Advance Directives:

Contact Number:

II. Health status History

Reason for admission:

Date and Time of Admission:

Diagnosis/Impression:

Pre Op Dx:

Post Op Dx:

Surgical Operation Performed:

Number of Days Post Op:

Attending Physician:

Usual Health status:

Relevant family History:

Past Health History:

A) Childhood Illness:

B) Hospitalization & Surgeries:

C) Serious Injuries:

D) Serious Chronic Illness:

E) Immunizations:

F) Allergies:

G) Medications:

H) Recent Travel:

I) Family History
Review of Systems

General Health Survey:

Skin, Hair, and Nails:

Head and Neck:

Eyes:

Ears:

Nose and Sinuses:

 Mouth and throat:

Respiratory:

Cardiovascular:

Breasts:

Gastrointestinal:

Genitourinary:

Reproductive:
 Neurological:

Musculoskeletal:

Immune/Hematologic:

Endocrine:

III. Psychosocial profile:

PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle information

2. Normal coping patterns

3. Understanding of present illness

4. Personality Style:
 5. History of Psychiatric Disorder:

6. Recent Life Changes or Stressors:

7. Major Issues Raised by Current Illness:

8. Mental Status Examination

APPEARANCE

Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact inappropriate makeup Others: ___________________

BEHAVIOR

Calm Appropriate Restless Agitated Compulsions

Unusual actions Others: __________________

Description:

SPEECH

Appropriate Pressured Loose Association Loud Soft

Mute Others: ________________________

Description:

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried Anxious

Angry Hopeless Others: _________________

Description:

THOUGHTS

Appropriate Low Self-Esteem Suicidal Ideations Hallucinations

Delusions Phobias Others: ______________________

Description:
ABILITY TO ABSTRACT

Impaired: YES NO

Description:

MEMORY

Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes:

Description:

ESTIMATED INTELLIGENCE

Below Average Average Above Average

Description:

CONCENTRATION

Able to Focus Easily distractible

Able to subtract backwards by 7s from 100 correctly until number _______________.

Description:

ORIENTATION

Person ______ Time _______ Place _______ Situation _______

Description: Unable to gather necessary information

JUDGEMENT

Realistic decision making: YES NO

Description: Unable to gather necessary information

INSIGHT

Good Fair Poor

Description:
 IV: Physical Assessment

Date and Time taken:

a) Primary Survey

Airway:

Breathing:

Circulation:

Disability:

b) Vital Signs

Temp:

PR:

RR:

BP:

Pain:

c) Secondary Survey

a) Height and Weight

 b) General Health survey

c) Integumentary

Skin

Hair

Nails:

d) Respiratory

Nose:

Chest:
 e) Cardiovascular

f) Gastrointestinal

g) Genitourinary

h) Reproductive

i) Musculoskeletal
 j) Neurological

HOW
PATIENT’S
CRANIAL NERVE ILLICITED/EXAMINATION SIGNIFICANCE
RESPONSE
PERFORMED

Hold the scent with one

nostril with the other
nostril occluded while the
CN I: Olfactory
patient closes eyes.
Repeat with the other
nostril.

Ask the patient to read

CN II: Optic headline of the newspaper
at 2 feet distance.

Place penlight in front of

patient and ask her to
follow it with eyes only as
it moves through the six
CN III, IV, VI: cardinal fields of gaze;
Oculomotor, assess papillary response
Trochlear and to light and
Abducens accommodation by
instructing the patient to
look straight as penlight s
shining through each
pupil.

Ask patient to clench teeth

while the nurse palpates
her temporal mandibular
joints and masseter
muscles for contractions;
use cotton wisps to stroke
CN V: Trigeminal
forehead, cheeks, and
chin and ask patient id
she is able to feel the
touch; use also sterile
cotton to test for corneal
reflex.

Instruct patient to smile,

CN VII: Facial raise eyebrows, frown and
puff cheeks.
 Occlude ear intermittently
and ask client to repeat
CN VIII:
whispered words at two
Vestibulocochlear
feet distance. Done on
both ears.

Assess patient’s ability to

swallow. Ask patient to
CN IX, X:
say “ah” while depressing
Glossopharyngeal
the tongue with a padded
and Vagus
tongue depressor. Check
for gag reflex.

Test for muscle strength.

Instruct client to shrug
CN XI: Spinal shoulders and turn head
Accessory from side to side while
applying resistance with
hands.

Test for the movement

CN XII: Hypoglossal and muscle strength of the
tongue.

V. Diagnostic Tests

VI. Summary of Significant Events

Date Event

VII. Collaborative Management

Doctor’s Order Nursing Diagnosis

VIII. Progress Notes

Focus Data Action Response

IX. Textbook Discussion and Schematic Diagram

X. Drug Study

XI. Nursing Care Plan