College of Nursing and Allied Health Sciences

NURSING CARE STUDY

(Application of Nursing Process)

Name: ___________________________________________ BSN ______Date:_____________

I. ASSESSMENT
A. General Information
Client’s Initials: RM/Wd: Date Admitted:
Age: Sex: CS:
Nationality: Religion:
Educ. Attainment: Occupation:

Admission complaint/s:
Admitting or Working Diagnosis:
Final Diagnosis (if applicable):
Surgery Performed (if applicable):

Admitting VS:
T: °C P: Beats/min R: Breaths/min
BP: mmHg Weight: lbs/kg Height: ft/cm

Arrived on unit by: Accompanied by:

Allergies:
Medications:

Brief description of diagnosis/surgery performed:

_____________________________________________________________________
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A. Nursing History (Based on the Functional Health Pattern by Gordon)

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
1.1 Client’s description of her/his health:
Before Admission:
At present:

1.2 Health Management:

Self
Family and Children

1.3 History of present illness:

1.4 Past illnesses:

1.5 History of hospitalization (when, where and why):

1.6 History of illness in the family:

1.7 Expectations of hospitalization:

1.8 Anticipation of problem with caring for self upon discharge:

1.9 Knowledge of treatment or practices prescribed:

 1.10 Reaction to above prescriptions:

The following guide will refer to the functional patterns before hospitalization

2. NUTRITION AND METABOLIC PATTERN

2.1 Usual food intake (before admission)
Breakfast
Lunch
Supper
Snacks
Preferences

2.2 Usual fluid intake (type, amounts):

Preferences:

2.3 Any food/fluid restrictions:

2.4 Any problems with ability to eat:

2.5 Any supplements (vitamins, feedings)

3. ELIMINATION PATTERN
3.1 Bladder:
Usual frequency/day: Color:
Complaints the usual pattern of urination
Home remedies:

3.2 Bowel:
Usual pattern/day (time, frequency, color and consistency)
Complaints of usual pattern of bowel movement:
Home remedies:

3.3 Any assertive device:

3.4 Skin: (condition)

4. ACTIVITY EXERCISE PATTERN

4.1 Usual daily/weekly activities
Exercise Leisure

4.2 Any limitations of physical ability:

4.3 History of dyspnea or fatigue

5. SLEEP-REST PATTERN
5.1 Usual sleep pattern: Bedtime Hours slept
No. of pillows Sleep routines

5.2 Any problems regarding sleep

5.3 Usual remedies:

6. COGNITIVE-PERCEPTUAL PATTERN
6.1 Any deficits in sensory perception (hearing, sight, touch)

6.2 Ability to read and write. Any difficulty in learning?

6.3 Any complaints? (e.g. pain)

7. SELF-PERCEPTION PATTERN
7.1 What the client is most concerned about

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 7.2 Present health goals

7.3 Effect of present illness to self:

7.4 How does the client see/feel about self?

8. ROLE-RELATIONSHIP PATTERN
8.1 Language spoken

8.2 Manner of Speaking

8.3 Significant person to client

8.4 Complaints regarding family

8.5 Living with (members of family)

9. SEXUALITY-SEXUAL FUNCTION
9.1 Anticipated change in sexual relations because of illness

9.2 Knowledge of sexual functioning

10. COPING-STRESS MANAGEMENT PATTERN

10.1 Decision making ability

10.2 Any significant stress in the past year

10.3Management of stress

10.4 Expectations from nurses to provide comfort and security during

hospitalization

11. VALUE BELIEF SYSTEM

11.1 Source of strength or meaning:

11.2 Importance of God to client:

11.3 Religious practices (type and frequency):

11.4 Request for religious person/practice

12. DEVELOPMENTAL TASKS (Assess for achievement of developmental

tasks significant to patient’s age)

a. Erik Ericson
b. Robert Havighurst
c. Sigmund Freud
d. Jean Piaget
e. James Fowler
f. Lawrence Kohlberg

A. PHYSICAL ASSESSMENT Date performed: _____________

1. Head-to-Toe Examination
1.1 General Survey

1.2 Vital Signs

1.3 Head and Face

a. Cranium
b. Temporal arteries

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 c. Face
d. Cranial nerves V and VII
e. Nose and cranial nerve I
1.4 Eyes and vision
a. External eye structure
b. Visual acuity
c. Extraocular muscle function (cranial nerve III, IV & VI)
d. Pupillary reflexes
e. Internal eye structure with ophthalmoscope

1.5 Ears & Hearing

a. External ear
b. Hearing
c. Ear canal and tympanic membrane with otoscope

1.6 Neck
a. Muscoloskeletal structures
b. Lymph nodes
c. Thyroid gland
d. Musculoskeletal function and cranial nerve XI
e. Carotid arteries

1.7 Upper Extremities

a. Musculoskeletal structures, skin, nails
b. Musculoskeletal functions
c. Brachial and radial arteries
d. Deep tendon reflexes

1.8 Anterior Chest

a. Breasts and axillae
b. Thorax
c. Precordium

1.9 Back
a. Musculoskeletal structure
b. Fist percussion over spine and kidneys
c. Posterior thorax

1.10 Neck veins

1.11 Abdomen
a. 4 abdominal quadrants
b. Specific organs
Liver
Spleen
Kidneys

I.12 Lower Extremities

a. Musculoskeletal structures, skin, and toe nails
b. Musculoskeletal function
c. Popliteal,posterior tibial and pedal arteries
d. Deep tendon reflexes and plantar reflex

I.13 Genitals and pelvis (Female)

a. External genitals
b. Vagina and cervix
c. Vagina, uterus and adnexa

(Male)
d. External genitals (penis and scrotum)
e. Hernias

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 I.14 Rectum

Summary of abnormal findings:

B. REVIEW OF RECORDS
1. Pertinent Data from the Doctor’s Order

2. Pertinent Data from the Nurse’s Notes

3. Significant Laboratory Tests

Date Laboratory Results Normal Significance Nursing

Performed Test Value of the Result Responsibilities

Other Diagnostic Examinations

Date Laboratory Results Normal Significance Nursing
Performed Test Value of the Result Responsibilities

C. DATA FROM TEXTBOOK

1. Definition of Diagnosis / Surgery Performed

2. Brief description of the Anatomy and Physiology

D. Paradigm of the pathophysiology of the disease:

_____________________________________________________________________________
Signs & Symptoms ‘ Signs and Symptoms manifested ‘
Found in the book ‘ by the client ‘ Rationale__________

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 Reference:

II. PLANNING
1. Problem List

Date . Prioritization
Identified : Nursing Diagnosis . Day 1 ‘ Day 2 ‘ Day 3 ‘ Day 4 _
‘ ‘ ‘ ‘ ‘ __
‘ ‘ ‘ ‘ ‘ ___
‘ ‘ ‘ ‘ ‘ ____
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2.1 Nursing Care Plan (from admission related to patho/based on disease process)
Nursing Diagnosis Goals/Objective Nursing Intervention Rationale

2.2 Nursing Care Plan (actual interaction during RLE)

Nursing Diagnosis Goals/Objective Nursing Intervention Rationale

III. IMPLEMENTATION (Charting)

Nursing diagnosis ‘ Nursing Intervention Implemented ‘ Evaluation ______
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IV. Drug Study

Name of Drug Indication Nursing Responsibility

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 DISCHARGE PLANS FOLLOW-UP EVALUATION

Date of possible discharge:

1. Medication to be taken at home

2. Diet

3. Activities restricted

4. Treatments

5. Special health teachings

6. Check-up schedule

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Health Teaching Guide
Topics
Time Allotment
Objectives ‘ Content ‘ Teaching Strategy ‘
Evaluation
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