INCLUDEPICTURE

"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
Far Eastern University
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni Institute of Nursing
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikiped
ia/en/7/7c/Official_Far_Eastern_Uni
versity_Logo.png" \*

MERGEFORMATINET

INDIVIDUAL/ GROUP NURSING PROCESS FORMAT

I. TITLE PAGE (1 whole page)

A Case of:
(Diagnosis)___________

Presented by:
Name of Student / Group / Section

Presented to/Submitted to:

Name of Faculty__________

Submitted on:
Date Submitted_________

II. DEMOGRAPHIC PROFILE (Page 2)

Demographic Data
Name:
 Address:
Age: Birth Date: Birth Place:
Gender:
Religion: Race/Ethnic Origin:
Occupation: Educational Attainment:
Marital Status: Name of Spouse:
Number of Children:
Chief Complaints:
Date of Admission:
Room & Bed Number:
Attending / Admitting Physician:
Admitting/Final Diagnosis:
Medical Insurance:

III. NURSING HEALTH HISTORY

A. History of Present Illness
1. Signs and Symptoms 4. Effect to other body parts/functions
2. Inclusive dates 5. Intervention/treatment done
3. Precipitating and alleviating factors 6. Effect of intervention/treatment

B. Past Health History

1. Immunizations 5. Accidents/Injuries
2. Childhood Illness 6. Hospitalizations
3. Past Illnesses 7. Surgical procedures done
4. Heredofamilial disease 8. Travels local and abroad

C. Obstetric History (For OB Patients ONLY)

D. Pediatric History (For PEDIA Patients ONLY)
(Developmental Milestone)
E. Occupational History (For ADULT patients ONLY)

Inclusive Dates/Years Occupation

F. Family History (Include genogram with legend)

Grandparents Grandparents

Aunts/Uncles Father Mother Aunts/Uncles

Spouse Patient Siblings

 Children

Legend:
------ - Committed relationship X - Deceased
- Female (Married)
- Male --//-- - Broken relationship (Divorced)

IV. GORDON’S HEALTH ASSESSMENT

1. NARRATIVE form
2. Analysis (with reference) & interpretation after each pattern

A. Health Perception – Health Management Pattern

♦ client’s perceived pattern of health and well-being and how health is managed.

B. Cognitive – Perceptual Pattern

♦ sensory, perceptual, and cognitive pattern according to age level

C. Self-perception – Self-concept Pattern

♦ self-concept and perception of self (body comfort, image, feeling state)

D. Role – Relationship Pattern

♦ pattern of role engagements & relationships according to ordinal position & role in society)

E. Sexuality – Reproductive Pattern

♦ pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive
patterns according to age level

F. Coping – Stress Tolerance Pattern

♦ general coping patterns and effectiveness of the pattern in terms of stress tolerance

G. Value – Belief Pattern

♦ pattern of values and beliefs, including spiritual and moral that guide choices or
decisions according to age level
ADL Before During Interpretation &
Hospitalization Hospitalization Analysis (with
reference)
H. Nutritional – Metabolic Pattern
a. pattern of food and fluid Consumption
relative to metabolic need
b. 3 day food recall with computations
I. Elimination Pattern
♦ pattern of excretory function
(bowel, bladder, & sweating/vomiting)
J. Activity – Exercise Pattern
♦ pattern of exercise, activity, leisure, and
recreation (7 days)
K. Sleep – Rest Pattern
♦ patterns of sleep, rest, and relaxation
(7 days)

V. PHYSICAL ASSESSMENT ( CEPHALO CAUDAL)

a. General Survey
b. Measurements (Height, Weight, BMI, Vital signs)

Assessment Body Part Norms Actual Findings Analysis & Interpretation

Method Used (Cephalo-caudal) (with reference)

VI. LABORATORY/DIAGNOSTIC EXAMINATIONS

Date Done Laboratory/Diagnostic Normal Values Actual Results Clinical Interpretation

Examination Interpretation & Analysis
(with reference)
VII. DRUG STUDY

Mechanism of
Contraindi- Adverse
Name of Drug Action Indication Side Nursing
cation Effects
Effects Responsibilities
Generic Name Classification

Brand Name Peak Effect

Route & Dosage

VIII. PATHOPHYSIOLOGY
A. Anatomy & Physiology
B. Overview of Disease
C. Contextual mapping/ Schematic Diagram

IX. ECOLOGIC MODEL

A. Hypothesis
B. Predisposing Factors
1. Agent
- a substance or force, either animate or inanimate, the presence or absence of which
may, following effective contact with the susceptible host, under proper
environmental conditions, serve as a stimulus to initiate and/or perpetuate the
disease process
a. Nutritive (Carbohydrates, Vitamins, Fat, Proteins, Mineral, Water)
b. Chemical (Pollutants, Pesticides, Cosmetics)
c. Physical (Collision, traffic accident, falling down, dust, climate
(Frost bite, heat stroke)
d. Infectious agent (Virus, Bacteria, Ricketsia, Fungi, Protozoa, Metazoa)
e. Mechanical
f. Psychosocial

2. Host
- intrinsic factors that influence an individual’s exposure, susceptibility, or
response to a causative agent.

a. Genetic e. Intercurrent infection i. Occupation

b. Age f. Human behavior j. Personality type
c. Sex / Gender g. Religion k. Social class membership
d. Ethnic/ Race h. Family size l. Resistance

3. Environment
- are extrinsic factors which affect the agent and the opportunity for exposure.

3.1. Physical
- geography - temperature/ humidity - geology
- weather / climate - Air quality - Noise

3.2. Biologic
- human population density
- fauna (animal life)
- flora (plant life)

3.3. Socio-economic
- urban overcrowding - workplace contain the agent - income
- social disruptions - Availability of health services - culture
- tensions & pressures

C. Ecologic Model
1. Lever
2. Wheel
3. Web

D. Analysis (with reference)

 E. Conclusion and Recommendation
(Include referrals)

X. Problem Identification and Prioritization

A. Level 2
Cues Inference Problem Statement

B. Level 3 and 4
Nursing Diagnosis Rank Justification
Cues according to ABC or Maslows

XI. NURSING CARE PLAN

Cues Nursing Analysis Goal Intervention Rationale Evaluation

Diagnosis
(with references) (Based on
Nsg prob)
Subjective Maybe a. Brief Objective a. Independent (With Narrative
NANDA explanation in (w/ EBN) reference) Based on
Objective OR NOT narrative form (Based on (Supplemental) objective
(at least 3 Etiology)
each) b. Start from b. Interdependent Parameters:
diagnosis, to SMART (Facilitative) Adequacy
the etiology to Effectiveness
symptoms c. Developmental Appropriateness
then end point Efficiency
is the nursing Acceptability
problem

XII. DISCHARGE PLAN (applicable ONLY if client is for DISCHARGE)

M – Medications to continue at home
E - Exercises
T - Treatments
H – Health Teachings
O – Out Patient (Date/Time/Place/Physician)
D - Diet
S – Sexuality/Spirituality

THE EBN PER LEVEL REQUIREMENT

A. EBN FORMAT FOR LEVEL II UP TO LEVEL III 1st SEM

1. General Question
2. Reconstruction of General Question related to client’s problem identified in the RLE.

a. COPES (Client-Oriented Practical Evidence Search)

Client type & problem What might you do Alternate course of action What you want to accomplish

(Specific statement of (Statement of (statement of the main (goal of the question: What the
the type of client of possible intervention) alternative course of practitioner hopes to accomplish or
interest and the intervention) find out from the research)
problem)
 b. PICO

Patient Intervention Comparison Outcome

Focus population

3. Critical Review with Summary of the Literature (Attach Literature to output)

B. EBN FORMAT FOR LEVEL III 2nd SEM

1. Formulation of Clinical Question approved by the Clinical Instructor based on the actual client’s
problem in the RLE

2. identify if COPE or PICO question

Type of Research Data Base Search Number of Number of Relevant Literature

Selected Literature Readings Relevant Literature Reference
(Primary or related to the related to Clinical
secondary, etc) Clinical Question Question
Experimental TRIP Data Base 30 6 Liu, JP., Yang, M.,
Liu, Y, et al (2006)
Herbal medicines for
treatment of irritable
bowel syndrome
(Cochrane Database
of Systematic
Reviews, Issue 1)

3. Critical Review with Summary of the Literature (Attach Literature to output)

C. EBN FORMAT FOR LEVEL IV

1. Formulation of Clinical Question approved by the Clinical Instructor based on the actual client’s
problem in the RLE

2. identify if COPE or PICO question

Type of Research Data Base Search Number of Number of Relevant Literature

Selected Literature Readings Relevant Literature Reference
(Primary or related to the related to Clinical
secondary, etc) Clinical Question Question
Experimental TRIP Data Base 30 6 Liu, JP., Yang, M.,
Liu, Y, et al (2006)
Herbal medicines for
treatment of irritable
bowel syndrome
(Cochrane Database
of Systematic
Reviews, Issue 1)

3. Answer the EBN Format:

Format for Evidence Based Nursing Process:

I. Clinical Question (PICO/PICOT)
Patient/Problem
Intervention
Comparison
Outcome
Time Bound

II. Citation: Title of the Journal article on a research related to your case

III. Study Characteristics:

a. Patients included (population and sample)
b. Intervention
 c. Comparison
d. Outcome monitored
e. Does the study focus on the significant problem in clinical practice

IV. Methodology/Design
a. Methodology
b. Design
c. Setting
d. Data sources
e. Has the original study been replicated?
f. What were the risk and benefit of the nursing actions/interventions tested in the study?

V. Results of the Study

Discuss briefly the result of the study. If the original study has been replicated, are the findings
similar in the variety of situations?

VI. Author’s Conclusions/Recommendations

a. What contribution to the client’s health status does the nursing action/intervention make?
b. What overall contribution to nursing knowledge does the study make?

VII. Applicability
a. Does the study provide a direct enough answer to your critical question in terms of type of
patients, interventions and outcome?
b. Is it feasible to carry out the nursing action in the real world?

VIII. Reviewer’s Conclusion/Commentary

IX. Evaluating Nursing Care Practices

a. Safety d. Effectiveness
b. Competence of the care provider e. Appropriateness
c. Acceptability f. Efficiency

X. Recommendation
INCLUDEPICTURE Far Eastern University
"http://upload.wikimedia.org/wikipedia/ Institute of Nursing
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
ty_Logo.png" \*
MERGEFORMATINET
INCLUDEPICTURE
"http://upload.wikimedia.org/wikipedia/
en/7/7c/Official_Far_Eastern_Universi
 ty_Logo.png" \*

MERGEFORMATINET

EVIDENCE BASED NURSING

Research journals should be up-to-date (year 2010 and up) from research databases (e.g. EBSCO) or from
original sources. Writing style and citation of sources should follow the APA format.

A. Anatomy of a good clinical question consists of:

1. How would you describe a group of patient similar to your client?
2. What are the most important characteristics of the patient? (This may include the primary problem,
disease or co-existing conditions)
3. Sometimes the gender, age, or race of a patient may be relevant to the diagnosis or treatment of a
disease.
B. Intervention, Prognostic Factor or Exposure
` 1. What main intervention, prognostic factor or exposure are you considering?
2. What do you want to do with a client? Why? And How?
a. Prevent a complication
b. Promote a healthy lifestyle
c. Resolve nursing problems
d. Facilitate nursing interventions
C. What factor may influence the prognosis of the client?
1. Age 3. Co-existing problems
2. Economic status 4. Familial factor
D. What was the client exposed to?
1. Cigarette smoke
2. Pollen
3. Asbestos
4. Pollutants
5. Others
E. Comparison
1. What is the main alternative to compare with the intervention?
2. Are you trying to decide between two interventions?
F. Outcome
1. What do you hope to accomplish, measure or effect
2. What are you trying to do for the patient
a. Relieve or eliminate the symptoms/discomfort
b. Reduce the number of adverse events
c. Improve functions

Note: The clinical question does not always need a specific comparison.

Patient/Problem Low back pain

Intervention Acupuncture
Comparison, if any Application of hot and cold compress
Outcome/s Relieves back pain
Promotes relaxation

G. From the given example, a clinical question can be devised:

Example: “Low Back Pain: Is acupuncture more effective than the application of hot and cold
compress in relieving back pain and promoting relaxation?”

H. Related Literature from research databases (e.g. EBSCO) and other sources.