COLLEGE OF NURSING

Xavier University
Ateneo de Cagayan

LEVEL IV
NURSING HISTORY AND ASSESSMENT RECORD

I. PATIENT’S PROFILE
Name of patient: Diagnosis:

Age: Attending physician:

Religion:

Date and time of admission: Civil Status:

Language/dialect spoken:
Informant:

Temperature: Pulse: Respiration: BP:

O2 sat: Height: Weight:

Chief complaint/ reason for hospitalization:

History of present illness:

Family Medical History:

( ) Heart disease ( ) Lung disease ( ) Substance Abuse
( ) Hypertension(both parents and patient) ( ) Renal disease

( ) Stroke ( ) Cancer
( ) Others:
 II. FUNCTIONAL PATTERN
A. NUTRITION/METABOLLIC PATTERN
Meal Pattern:
Appetite: ( ) Good ( ) Fair ( ) Poor
Changes in eating habit: ( ) Yes ( ) No
Appetite changes: ( ) Yes ( ) No
Weight loss/gain:
Special diet:

Comments/ Nursing problems identified:

BMI ( kg/m² )= (weight in pounds * 703) =

height in inches²
BMI score range:
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater

Comments/ Nursing problems identified:

B. ELIMINATION PATTERN
Bladder : ( ) No difficulty ( ) Dysuria ( ) Oliguria
( ) Incontinence ( ) Nocturia ( ) Anuria
( ) UTI ( ) Stones ( )On catheter
Comments/Nursing problems identified:

Bowel: ( ) No difficulty ( ) Constipation ( )

COlostomy
( ) Incontinence ( ) Ileostomy
Comments/ Nursing problems identified:

C. SLEEP/REST PATTERN
( ) No difficulty ( ) Yes (describe)
Use of sleeping aids: ( ) Yes ( ) No
Comments/ Nursing problems identified:

D. ACTIVITY/ EXERCISE
Activities of Daily Living ( I= Independent; A=w/ Assistance; D=Dependent)
( ) Eating ( ) Bathing ( ) Dressing
( ) Grooming ( ) Toileting ( ) Ambulating

Activity Level: ( ) Active ( ) Sedentary

Comments/Nursing problems identified:

E. COGNITIVE PERCEPTION PATTERN

 Glasses: ( ) Yes ( ) No Contact Lens: ( ) Yes
( ) No
Hearing Aids: ( ) Yes ( ) No [ ] right
[ ] right [ ] left
[ ] left Prosthesis: ( ) Yes ( )No
[ ] right [ ]left
Comments/Nursing problems identified:

F. BEHAVIOR PATTERN (COPING/ VALUES)

Behavior: ( ) Relaxed ( ) Mildly Anxious
( ) Moderately Anxious ( ) Very Anxious
Psychiatric History:"
SUBSTANCE ABUSE:
Tobacco ( ) Yes (X) No
Drugs ( ) Yes (X) No
Alcohol ( ) Yes (X) No
Cigarrete/Cigar/pipe ( ) Yes (X) No
Comments/Nursing problems identified:

G. PAIN
( ) None ( ) Present (describe)
Present pain management:

Comments/Nursing problems identified:

H. SEXUALITY/ REPRODUCTION HEALTH

Date of last Pap Smear:
Is Patient pregnant? ( ) No ( ) Unsure ( ) Yes, # of weeks
Breast (cyst/lump/discharge): ( ) No ( ) Yes
Testicular/prostate problem: ( ) No ( ) Yes
Birth Control: ( ) NA ( ) No ( ) Yes (describe)
Comments/Nursing problems identified:

I. ROLE RELATIONSHIP PATTERN

Occupation:

With whom does patient live:

Anticipating to return home: ( ) Yes ( ) No:

Persons available to assist at home:

Comments/Nursing problems identified:

III. PHYSICAL ASSESSMENT (Indicate subjective and objective cues for

abnormalities noted.)
A. NEUROLOGICAL ASSESSMENT
SUBJECTIVE OBJECTIVE
Alert and oriented to person, place and time

Pupils equally round & reactive to light

Paresthesia (weakness) or paralysis of extremities __________

No difficulty of speech and swallowing noted ________

B. RESPIRATORY ASSESSMENT
Resp. 12-22 cpm at rest

Respirations quiet and regular

Breath sounds in both lung fields clear

Nail beds and lips pink

C. CARDIOVASCULAR ASSESSMENT
Regular apical pulse; Heart rate 60-100 bpm.

No complaints of chest pain and edema

D. PERIPHERAL-VASCULAR ASSESSMENT
Extremities pink, warm & movable w/in

normal ROM Peripheral pulses palpable

No edema No complaints of numbness/

calf tenderness

E. GENITOURINARY ASSESSMENT
Voiding without discomfort or difficulty

Urine clear, frequency w/in own pattern

No unusual vaginal or penile

discharges/ irritation noted

F. MUSCULOSKELETAL ASSESSMENT
Absence of joint swelling & tendernesss,

no evidence of inflammation.

Normal ROM of all joints. No muscle

Weakness. No complaints of back pain

G.INTEGUMENTARY ASSESSMENT
Skin color w/in patient’s norm

Skin warm, dry, intact

Decubitus/ buirns present? ( ) yes ( ) no

Skin/Burns

CURRENT MEDICATIONS :
Does the client have correct knowledge of the medications taken? If no, provide
comments.
1. ( ) Yes ( )
No___________________
2. ( ) Yes ( )
No___________________
3. ( ) Yes ( )
No___________________
4. ( ) Yes ( )
No___________________
5. ( ) Yes ( )
No___________________
6. ( ) Yes ( )
No___________________
7. ( ) Yes ( )
No___________________
8. ( ) Yes ( )
No___________________
9. ( ) Yes ( )
No___________________
10. ( ) Yes ( )
No___________________

Comments/Nursing problems identified:

PRIORITY NURSING DIAGNOSIS IDENTIFIED:

1
2
3
4
5