Beruflich Dokumente
Kultur Dokumente
Clinical Instructor_________________________________
Area of Assignment___________________________________
Date Submitted___________________________________
NURSING ASSESSMENT I
PATIENTS PROFILE
Name_______________________________________
Address__________________________________________________________
Sex_________
Religion________________________
Occupation________________________
Age_______
Civil Status______________________
HEALTH HABITS
Frequency
1. Tobacco
2. Alcohol
3. OTC-drugs/ non-prescription drugs
_______________
_______________
_______________
Amount
_____________
_____________
_____________
Period/Duration
_____________
_____________
_____________
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)
2. Hospital Environment
E. SUMMARY OF INTERACTION
Mental Illness
______
Rheuma/Arthritis ______
others (pls. specify)
______
REVIEW OF SYSTEMS
Name_____________________________
Date________________
Vital Signs:
Height_______________
Temperature_________
Weight______________
Pulse________
Observation____________________________________________________________________
Respiration__________
______________________________________________________________________________
Blood Pressure__________
______________________________________________________________________________
1. GENERAL
2. HEENT
3. INTEGUMENT
ARY
1. RESPIRATORY
2. CARDIOVASCUL
AR
3. DIGESTIVE
4. EXCRETORY
5. MUSCULOSKELE
TAL
6. NERVOUS
7. ENDOCRINE
DRUG STUDY
BRAND NAME
GENERIC NAME
CLASSIFICATION
Prescribed
dosage,
frequency, route
of administration
Mechanism
Of
Action
Indication
Contraindication
Adverse Reaction
Nursing
Responsibilities
NURSING ASSESSMENT II
Name___________________________________________________________
Chief Complaint___________________________________________________
Impression/Diagnosis______________________________________________
Date/Time of Admission____________________________________________
Diet_____________________________________________________________
Type of Operation (if any)___________________________________________
NORMAL PATTERN
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/supplem
BEFORE
HOSPITALIZATION
Age______
Sex_______
CLINICAL APPRAISAL
INITIAL
DAY 1
DAY 2
ent 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)
RESULT
NORMAL VALUE
NURSING IMPLICATION
DROP DATE
NUMBER OF
HOURS
DATE/TIME
CONSUMED
SUMMARY OF MEDICATION
DATE
Remarks
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN
NAME_______________________________________________
DATE OF DISCHARGE___________________________
1. MEDICATIONS
2. EXERCISE
3. DIET
4. HEALTH TEACHING
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION