West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING PROCESS GUIDE

(Adult)

I. VITAL INFORMATION

Name: (initials only) Date of Interview:

Age: Informant:
Sex: Relationship to Patient:
Address:
Civil Status:
Date and Time Admitted:
Chief Complaint: (“What is troubling you?”; What brought you to the hospital?”; Should be
recorded in client’s own words.)
Ward:
Bed No.:
Allergies:
Religious Affiliation:
Physician’s Initial:
Impression/Diagnosis:
Pre-op Diagnosis (optional):
Post-op Diagnosis (optional):
Surgical Operation Performed (optional):
Days Post-op (optional):

II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY

1. History of Present Illness (Write in a paragraph form)

a. Usual Health Status (“How would you describe your health up until this time?”)
b. Chronologic Story (Narrative section where client’s cc is documented in the proper
sequence of events)
1. When the symptoms started.
2. Whether the onset of symptoms was sudden or gradual.
3. If available, specific dates when the problem was experienced.
4. How often the problem occurs.
5. Exact location of the distress.
6. Character of the complaint (e.g. intensity of pain or quality of sputum,
emesis or discharge)
7. Amount of discharge, mucus, blood, stool, or urine, or size of lesion.
8. Activity in which the client was involved when the problem occurred.
9. Phenomena or symptoms associated with the chief complaint.
10. Factors that aggravate or alleviate the problem (e.g.: medications taken,
dosage and frequency, for how long?; consultation made?)
c. Relevant Family History (related problems of family members)
d. Disability Assessment (how the problem has interfered with the patient’s daily life in
terms of work or school and family resources and relationship)

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2. Past Health Problems/Status
a. Childhood Illness
b. Immunization (type and date received)
c. Allergies (to drugs, animals, insects, or other environmental agents and the type of
reaction that occurs)
d. Accidents and Injuries (how, when, and where the incident occurred, the type of
injury, treatment received, and any complications)
e. Hospitalization for serious illnesses (reasons for hospitalization, dates, location of
the hospital, name of the physician, surgery performed, course of recovery,
and any complications)
f. Medications (all currently used prescription and over-the-counter medications, such
as aspirin, nasal spray, vitamins or laxatives; include dosage, frequency of taking,
and for how long)

3. Family History of Illness (heart disease, cancer, diabetes, hypertension, obesity, allergies,
arthritis, tuberculosis, jaundice, bleeding, ulcers, migraine, alcoholism, mental illness;
specify family member or relative affected, indicate if from maternal or paternal side)

4. Patient’s Expectations (verbatim)

a. What does he/she expect to occur during this hospitalization?
b. What does he/she expect regarding nursing care?

5. Patterns of Functioning

a. Breathing Patterns
Respiratory Problems: (any chest pains, cough, shortness of breath, wheezing,
coughing up blood, lung disease such as PTB, emphysema, asthma,
bronchitis? What triggered the attack? How often experienced?; Have
you ever had a chest x-ray? When? Results?)
Usual Remedy: (“What offers relief?”)
Manner of Breathing: (character, rhythm, etc.)

b. Circulation
Usual Blood Pressure:
Any history of chest pain, palpitations, coldness of extremities, etc. (heart
disease, heart murmur, high blood pressure, anemia, varicose veins, leg
swelling, or ulcers)

c. Sleep Patterns
Usual bedtime:
Number of pillows: (specify placement)
Bedtime Rituals: (“What do you do to prepare for sleep?”)
Problems regarding sleep:
Usual Remedy:

d. Drinking Patterns:
Kinds of Fluid in 24 hours/Amount in mL or Number of Bottles: (approximate;
should also include intake of alcohol, coffee, cola, tea, and etc.; describe
type, number of bottles or glasses per day, and pattern of drinking; e.g.
morning, evening or weekends)

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 e. Eating Patterns

Usual Food Taken Time

(quantify) (range)
Breakfast
Lunch
Dinner
Snacks

Food likes:
Food dislikes:

f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems or Difficulties:
Usual Remedy:
2. Urination
Frequency:
Problems:
Usual Remedy:

g. Exercise:

h. Personal Hygiene
1. Bath
Type:
Frequency:
Time of Day:
2. Oral Care
Frequency:
Care of Dentures:
3. Shaving
Frequency:
4. Use of Cosmetics:

i. Recreation:

j. Health Supervision:

II.B.: CLINICAL INSPECTION

Date and Time taken:

II.B.1. Vital Signs:
T= PR =
BP = RR =

II.B.2. Height:
II.B.3. Weight:

II.B.4. PHYSICAL ASSESSMENT

General Appearance: (posture and gait, over-all hygiene and grooming, body and
breathe odor in relation to activity level, signs of distress in posture or facial
expression, obvious signs of health or illness)

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A. INTEGUMENTARY SYSTEM

B. NEURO-SENSORY SYSTEM

C. RESPIRATORY SYSTEM

D. CARDIOVASCULAR/CIRCULATORY SYSTEM

E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM

F. GENITO-URINARY SYSTEM

G. REPRODUCTIVE SYSTEM

H. ENDOCRINE SYSTEM

I. MUSCULOSKELETAL SYSTEM

J. LYMPHATIC SYSTEM

K. HEMATOPOEITIC SYSTEM

II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle information

2. Normal coping Patterns

3. Understanding of Present Illness

4. Personality Style:

5. History of Psychiatric Disorder:

6. Recent Life Changes or Stressors:

7. Major Issues Raised by Current Illness:

8. Mental Status Examination

(Circle the correct words. Include a short description of client for each area assessed.)

APPEARANCE
Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact Inappropriate makeup others: _______________

Description:

BEHAVIOR
Calm Appropriate Restless Agitated Compulsions

Unusual actions others: _______________

Description:

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 SPEECH
Appropriate Pressured Loose Association Loud Soft

Mute others: _______________

Description:

MOOD/AFFECT
Appropriate Labile Flat Depressed Worried Anxious

Angry Hopeless others: _______________

Description:

THOUGHTS
Appropriate Low Self-Esteem Suicidal Ideations Hallucinations
Delusions Phobias others: _______________

Description:

ABILITY TO ABSTRACT
Impaired: YES NO

Description:

MEMORY
Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes:

Description:

ESTIMATED INTELLIGENCE
Below Average Average Above Average

CONCENTRATION
Able to focus Easily distractible
Able to subtract backwards by 7s from 100 correctly until number ___.

ORIENTATION
Person ___ Time ___ Place ___ Situation ___

JUDGMENT
Realistic decision making: YES NO

Description:

INSIGHT
Good Fair Poor

Description:

Adapted from Gorman, L. D. Sultan, & M.L. Raines. (2000). Psychosocial nursing for
general patient care. USA: Lexi-Comp Inc.

II.C. NURSING PROGRESS NOTES (On-going Appraisal)

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 (Use SOAPIE format. Refer to example given)
4/12/10
8:00 a.m. S - “My skin is itchy on my back and arms, and it’s been life this for a
week.”

O - Skin appears clear-no rash or irritation noted. Marks where client

has scratched noted on left and right forearms. Allergic to
Elastoplast but has not been in contact.
No previous history of pruritus.

A - Altered comfort (pruritus): cause unknown

P/I - Instructed not to scratch skin.

8:30 a.m. Applied calamine lotion to back and arms.
Assisted to cut fingernails.
Assessed further to determine whether recurrence associated with
specific drugs or foods.
Referred to physician and pharmacist for assessment.

11:00 a.m. E - States, “I’m still itchy. That lotion didn’t help.”

Source: Berman, A. Snyder, S., Kozier, B., Erb, G. (2008). Fundamentals of Nursing: Concepts,
Process, and Practice. 8th Ed. Singapore: Pearson Education Inc.

II.D. OTHER SOURCES OF DATA

1. CLINICAL CHEMISTRY
Name of Examination:
Definition:
Preparation:
Purpose:
Date:

Significance
Results Normal Values
of Abnormal Results

2. HEMATOLOGY
Name of Examination:
Definition:
Preparation:
Purpose:
Date:

Significance
Results Normal Values
of Abnormal Results

3. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS

Name of Examination:
Definition:
Preparation:
Purpose:
Date:
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 Results:
Impression:
Significance:

III. DRUG STUDY (Observe 10 rights in drug administration; include IV drugs)

IV. TEXTBOOK DISCUSSION

a. Definition

b. Signs and symptoms

 Signs and symptoms must be reflected at the side
 Straight line (not in red) – for signs and symptoms manifested by the patient
 Broken line – for signs and symptoms NOT manifested by the patient

Signs and Symptoms Signs and Symptoms

According to Textbook Manifested by the Patient
Delusions (+) delusions of grandeur (4/12/10)
Hallucinations (+) auditory hallucinations – command
hallucinations (4/12/10)
Looseness of Association (-)
Anhedonia (-)
Avolition (-)

c. Pathophysiology (Schematic Diagram)

Predisposing Factors Precipitating Factors

- conditions placing a patient at a high - a condition leading to an
risk to develop a disease condition abnormality

Discuss the

s/sx progress of the s/sx

disease s/sx

Disease Condition

d. Management
1. Nursing
2. Medical
3. Surgical (if applicable)
Sources: (at least 5 references)

V. PROBLEM LIST (Identified Nursing Diagnoses numbered according to priority)

VI. NURSING CARE PLAN