Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student_____________________________________ Area of Assignment___________________________________ Clinical Instructor_________________________________ Date

Submitted___________________________________ NURSING ASSESSMENT I PATIENTS PROFILE Name_______________________________________ Sex_________ Religion________________________ Address__________________________________________________________ Civil Status______________________ Age_______

Occupation________________________

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)

FAMILY HISTORY WITH GENOGRAM Acquired Diseases: Hypercholesterolemia Kidney Diseases Tuberculosis Alcoholism Drug Addiction Hepatitis A B C Others (pls. specify) D. PATIENTS PERCEPTION OF: 1. Present Illness _______ _______ _______ _______ _______ _______ _______ _______ _______ Heredo- familial Diseases: Diabetes Heart Diseases Hypertension Cancer Asthma Epilepsy Mental Illness Rheuma/Arthritis others (pls. specify) ______ ______ ______ ______ ______ ______ ______ ______ ______

2. Hospital Environment

E. SUMMARY OF INTERACTION

REVIEW OF SYSTEMS Name_____________________________ Vital Signs: Temperature_________ Pulse________ Respiration___________ Blood Pressure________ Date________________ Height_______________ Weight______________ Observation____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

1. GENERAL

2. HEENT

3. INTEGUMENTARY

4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10. 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)___________________________________________

Age______

Sex_______

Inclusive Dates of Care ___________________ Allergies___________________________

NORMAL PATTERN

BEFORE HOSPITALIZATION

INITIAL DAY 1

CLINICAL APPRAISAL DAY 2

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/supplement 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)

LABORATORY AND DIAGNOSTIC PROCEDURES DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

SUMMARY OF INTRAVENOUS FLUID DATE/TIME STATED INTRAVENOUS FLUID AND VOLUME DROP DATE NUMBER OF HOURS DATE/TIME CONSUMED

SUMMARY OF MEDICATION DATE MEDICATIONS- dosage, frequency, route Remarks

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

NURSING MANAGEMENT

SURGICAL MANAGEMENT

DISCHARGE PLAN NAME_______________________________________________ CONDITION UPON DISCHARGE_________________________________ DATE OF DISCHARGE___________________________ Nature: Home per request ( ) Discharge against medical advice ( )

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION