West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City

N U R S I N G P R O C E S S : EMERGENCY & DISASTER NURSING

I. VITAL INFORMATION Name: Birthday: Age: Sex: Civil Status: Address: Religious Affiliation: Educational Attainment:

Date of Interview: Informant: Relationship to Patient:

Date and Time of Consultation: Date and Time of Admission: Chief Complaint : Impression/ Diagnosis : Attending Physicians Initials & Specialization: Initials of Resident-in-Charged & Specialization: Triage Category :

Department: Ward:

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

b. Chronologic Story

c. Relevant Family History

d. Disability Assessment

2. Past Health Problems a. Childhood Illness

b. Immunizations

c. Accidents and Injuries

d. Allergies

e. Maintenance Medications

f. Previous Hospitalizations

g. Last Meal Taken

B. CLINICAL INSPECTION

1. Primary Survey a. Airway

b. Breathing

c. Circulation

d. Disability

2. Secondary Survey Height: Weight: A. Integumentary System Pulse Rate: Respiratory Rate: Blood Pressure:

B. Neurologic System

c. Respiratory System

d. Cardiovascular System

e. Gastrointestinal System

f. Genitourinary System

g. Reproductive System

h. Endocrine System

i. Lymphatic System

j. Musculoskeletal System

k. Hematopoietic System

C. PSYCHOSOCIAL ASSESSMENT 1. Lifestyle Information

2. Normal Coping Patterns

3. Understanding of Current Illness

4. Personality Style

5. History of Psychiatric Disorder

6. Recent Life Changes/Stressors

7. Major Issues Raised by Current Illness

8. Mental Status Examination A. Appearance Neat clean disheveled inappropriate makeup Description:

poor grooming erect posture good eye contact

B. Behavior Calm appropriate restless agitated compulsions unusual actions Description: C. Speech Appropriate Description: D. Mood/Affect Appropriate Description:

pressured loose association loud soft mute

labile

flat depressed worried anxious angry hopeless

E. Thoughts Appropriate phobias Description:

low self-esteem

suicidal ideations

hallucinations delusions

F. Ability to abstract Impaired Description:

Yes No

G. Memory Impaired recent memory Yes No Impaired past memory Yes No No. of objects able to remember after 5 mins: Description:

H. Estimated Intelligence Below average average Description:

above average

I. Concentration Able to focus Description:

easily distractible

J. Orientation Person Description:

Time

Place

Situation

K. Judgment Realistic Decision-Making: Description:

Yes

No

L. Insight Good Fair Description:

Poor

D. SCHEMATIC DIAGRAM OF MEDICAL DIAGNOSIS

E. DIAGNOSTIC/ LABORATORY/ RADIOLOGIC TESTS:

Dat e Procedure Don e Invasive/ NonInvasive Rationale Res ult Significance

F.COLLABORATIVE MANAGEMENT a. Medical Management/ Interventions

b. Surgical Management/ Interventions

H. NURSING MANAGEMENT a. List of Prioritized Nursing DIagnoses