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Mindanao State UniversityCOLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student _____________________________________________________ Clinical Instructor ________________________________

Area of Assignment __________________________________________________ Date Submitted _________________________________

NURSING ASSESSMENT I

PATIENTS PROFILE

Name Address Age

Sex Religion Civil Status Occupation

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco ________________ ______________ _________________ 2. Alcohol ________________ ______________ _________________ 3. OTC-drugs/ non-prescription drugs ________________ ______________ _________________

A. CHIEF COMPLAINTS

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previoustreatment and results, social and vocational responsibilities, affected diagnoses)


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C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses,allergies, habits, birth and development history, nutrition- for pedia)

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo-familial Diseases:Hypercholesterolemia _______ Diabetes _______ Kidney Disease _______ Heart Diseases _______ Tuberculosis _______ Hypertension _______ Alcoholism _______ Cancer _______ Drug Addiction _______ Asthma _______ Hepatitis A _______ Epilepsy _______

B _______ Mental Illness _______ C _______ Rheuma/Arthritis _______

Others (pls. specify) _______ Others (pls. specify) _______

D. PATIENTS PERCEPTION OF:

1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION


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REVIEW OF SYSTEMS

Name: ________________________________________ Date:

Vital Signs: Height:

Temperature Weight :

Pulse Observation _________________________________________________Respiration ____________________________________________________________

Blood Pressure

_____________________________________________________________

1. GENERAL

2. HEENT

3. INTEGUMENTARY


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4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10. ENDOCRINE


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NURSING ASSESSMENT II

Name _ ______________________________________________________ Age _ _________________ Chief Complaint ______________________________________________ Sex ____________________ Impression/Diagnosis _________________________________________Date/Time ___________________________________________________ Inclusive Dates of Care _____________________________Diet ________________________________________________________ Allergies _________________________________________

Type of Operation (if any) ______________________________________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 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. Meds/Supplementfood


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3. ELIMINATION

a. Urine (frequency color,transparency)

b. Bowel (frequency,color,consistency)

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 fivesenses:

(sight, hearing, smell,taste, touch)


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6. OXYGENATION

a. Vital Signs

Temperature

Respiratory Rate

Heart Rate

Blood Pressure

b. Lung Sounds

c. History ofRespiratoryProblems

7. PAIN COMFORT

a. Pain (location, onset,character, intensity,duration, associatedsymptoms,

aggravation)

b. Comfort measures/Alleviation


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c. Medications

8. HYGIENE AND ACTIVITIES

OF DAILY LIVING


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9. SEXUALITY

a. female (menarche,menstrual cycle, civilstatus, number ofchildren, reproductivestatus)

b. male (circumcision, civilstatus, number of

children)


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NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


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NURSING CARE PLAN



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NURSING CARE PLAN



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DRUG STUDY

Generic NameBrand Name

Classification

Prescribed,Recommended

Dosage, frequency,And route of

administration

Mechanism of Action Indication Contradiction Adverse Reaction NursingResponsibilit


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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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DRUG STUDY


Classification



administration



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NURSING MANAGEMENT


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MEDICAL MANAGEMENT

IdealActual

UA


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SURGICAL MANAGAEMENT

.


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ANATOMY AND PHYSIOLOGY


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LABORATORY AND DIAGNOSTIC PROCEDURES

DATENAME OF THEPROCEDURE

RESULT NORMAL VALUE NURSING IMPLICATION

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