JH CERILLES STATE COLLEGE
Pagadian Annex
West Capitol Road, Balangasan District
Pagadian City
In consortium with
WESTERN MINDANAO STATE UNIVERSITY
Zamboanga City
Name of Student: ____________________________________
Section - ________________________ Clinical Instructor: ________________________________
Area of Assignment: __________________________________ Date Submitted: __________________________________
NURSING ASSESSMENT I
PATIENT’S 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, 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
Legend: Acquired Diseases: Heredo- familial Diseases:
- Male Hypercholesterolemia _______ Diabetes ______
Kidney Diseases _______ Heart Diseases ______
- Female Tuberculosis _______ Hypertension ______
Alcoholism _______ Cancer ______
-patient Drug Addiction _______ Asthma ______
Hepatitis A _______ Epilepsy ______
B _______ Mental Illness ______
C _______ Rheuma/Arthritis ______
Others (pls. specify) _______ others (pls. specify) ______
D. PATIENT’S PERCEPTION OF:
1. Present Illness –
2. Hospital Environment –
E. SUMMARY OF INTERACTION
REVIEW OF SYSTEMS
Name____________________________ Date_______________
Vital Signs: Height_____________
Temperature_________ Weight_____________
Pulse_______
Observation____________________________________________________________________
Respiration__________
Blood Pressure_________
1. GENERAL
2. HEENT
3. INTEGUMENTARY
1. RESPIRATORY
2. CARDIOVASCULAR
3. DIGESTIVE
4. EXCRETORY
5. MUSCULOSKELETAL
6. NERVOUS
7. ENDOCRINE
NURSING ASSESSMENT II
Name: _____________________________________________________ Age: _______ Sex: _______
Chief Complaint: _____________________________________________
Impression/Diagnosis: ________________________________________
Date/Time of Admission: ______________________________________ Inclusive Dates of Care: __________________
Diet: ______________________
Age_______________________ Allergies: ______________________________
Type of Operation (if any):_______________________________________
CLINICAL APPRAISAL
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL
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. 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
Hematology:
WBC
RBC
Hematocrit
Hemoglobin
Lymphocyte
Platelet Count
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME
DATE/TIME STATED INTRAVENOUS FLUID AND VOLUME DROP DATE NUMBER OF HOURS
CONSUMED
SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks
DRUG STUDY
BRAND NAME Prescribed dosage, Mechanism
Nursing
GENERIC NAME frequency, route of Of Indication Contraindication Adverse Reaction
Responsibilities
CLASSIFICATION administration Action
BRAND NAME:
Generic name:
CLASSIFICATIONS:
GENERIC NAME:
BRAND NAME:
CLASSIFICATION:
GENERIC NAME:
BRAND NAME:
CLASSIFICATION:
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
PREDISPOSING FACTOTRS: PRECIPITATING FACTORS:
C D
MEDICAL MANAGEMENT
(IDEAL)
NURSING MANAGEMENT
Actual Ideal
DISCHARGE PLAN
NAME_______________________________________________ DATE OF DISCHARGE___________________________
CONDITION UPON 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
S:
