Taibah University ‫جامعة طيبة‬

Al-Madinah Al-Munawara ‫المدينة المنورة‬

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

NURSING ASSESSMENT FORM – MS 2

Student Name_____________________________ Year Level & Group:__________

Affiliating Hospital: _______________________________ Date:_____________
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I. Demographic Data

Patient Name: _____________________________ Medical Record No.:__________

Nationality: Saudi _____ Gender: Male_ Age: eight years and 7 months old
Occupation: __student ___ Marital Status: _______single_______
Attending Physician: ________________________ Room & Bed No. :pediatric
Date of Admission: 22/1/2023 ___Time of Admission: __10 : 00 pm _________
Admission Diagnosis: acute gastroenteritis

II. Health History (Subjective Data)

Chief Complaints: abdominal pains with diarrhea, vomiting

____________________________________________________________________

History of Present Illness:

The patient admitted to emergency department with complaints of abdominal pain for 2 days,
associated with vomiting for 2 days and Diarrhea for 2 days.
____________________________________________________________________

Past History: (includes previous illness, hospitalizations, surgeries & other management)

He was taking Covid 19 vaccination before 2 years

No previous illness or hospitalization or surgery
__________________________________________________________________

Past Medications & Allergies:

__________________________________________________________________________
___________________________nill___________________________________
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

Family History:

His father ( Hypertension) grand father (Hypertension)

and other family numbers is healthy
__________________________________________________________________________
_________________________________________________

Lifestyle Pattern:
Nutritional status: anorexia . Diet with low high intake
Exercise: he plays during day from 2 to 3 hours
He usually go to school walking in the morning. And come to home afternoon.
Sleep Pattern: he good sleeping patterns. He sleep 7 _9 hours dialy
Weight: 24 kg. Height: 123 cm. BMI = 15.86 kg/m2 (Normal)
____________________________________________________________________

III. Physical Assessment (Objective Data)

General Survey/Appearance:
The patient is conscious, well oriented of her present condition
The patient’s Vital Signs : a temperature 38.4c heart rate 100 bpm,
respiratory rate 20 b /min
BP : 102 /54 mmhg

Patient is lethargic, , has dry lips, skin and oral mucosa, and few
tear
____________________________________________________________________

Height: q2e cm. Weight: 23 kg.

Vital Signs:

Temperature: 37.5. Pulse Rate: 100 bpm Respiratory Rate:20 bpm SaO2:__95 % BP:
102 /54 mmhg Mean Arterial Pressure (MAP) ________
Pain Scale 5/ 10 (0 -10)
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

Body Part Assessment Findings Analysis

Examined Technique Used
the skin is intact a with Normal
Inspection and pink color
Skin and nails palpation
and Temperature is
38.4c, .. no pressure
ulcer observed, mucous
membranes is moist ,
skin turgor is instant
recoil (1sec)
Nails is bright. Clean,
Short no deformities
Inspection Inspection of the hair is Normal
Healthy condition short
black color and evenly
Hair distributed. No signs of
infection and infestation
observed.

Review of Systems (Head to Toe Assessment)

Continuation….
Normal
Head: appearance is
Inspection and
palpation normocephalic scalp is
Head, Nose, ears, eye, intact W/O crepitus,
mouth or clicks on palpation..
Mouth: dry lips and oral
mucosa, teeth intact no
breath odor.
Eyes: eye movement is
symmetrical and smooth,
without swelling or
redness
Nose: is Both nares are
patent bilaterally
no congestion or mucous
Ear : hear is normal
Inspection and Through inspection of Normal
auscultation chest is symmetrical no
Respiratory System tenderness.
Respiratory rate is within
normal 20 breath per
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

minute, breathing pattern

is normal no cough or
wheezing
The patient does not use
an accessory muscle for
respiration.
Cardiovascular Heart rate, beat , rhythm I write from doctor
system is regular , rate is 100 note
Auscultation +
Palpation
b/min .: the apical pulse
is palpable. S1 and S2 are Except. Pulse
presen in auscultation I'm measured it
without any extra heart
sounds.
Capillary beds refill is
within 3 sec
Inspection Inspection of Abdominal Spasms and rumbling
+auscultation + is normal shape ,soft result infection
Or gastritis
round skin is intact.
Bowel sounds are
Abdomen Hyperactive , Auscultate
spasms and rumbling in
lower abdominal
Inspection dehydration
results vomiting and
diarrhea
The urine Normal
Inspection is contained Frequency
Genito-urinary of urination is 4-5 times
system per day , yellow color no
catheterization observed
Inspection ROM: patient has an Normal
active range of motion.
No limits range of motion
Musculoskeletal Assistive devices: no
system assistive devices are used
Movement is rhythmic
and coordinated.
The Patient LOC : is Normal
conscious ,oriented , GCS
Inspection and
interview
15 /15 , ,pt is oriented
Neuro system ×3( time and person
,place,)
He is good concentration
and memory, no
dizziness or numbness or
tingling sensation
Good sense for touch.
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

https://t.me/nurse_helping

IV. Laboratory Investigations & Diagnostic Procedures

A. Laboratory Investigations

Laboratory Test Normal Values Patient value Remark

WBC 4 _ 11 *10^9 /l 11.5 *10^3 /ul High
RBC 4.0 _5. 5 *10^6 _4.02 *10^6 /ul Normal)
/ul
HGB 11.2 _14.5 g/dl 12.9 g/dl Normal
Iron 5 to 29 umol/L 10.9 umol/L Normal
Platelets count 200_450 449 *10^3 /ul Normal
*10^3/ul
HCT 30_ 44 % 41.1 % Normal
Urea 2.5 _6.5 3.9 mmol/L Normal
mmol/L
Pt 11.6 _14.1 sec 11.0 sec Normal
Albumin 25 _50 g/L 49 g/L Normal
Potassium 3.5 _5.2 mmol/L 4.32 mmol/L Normal
Sodium 135 _145 136 mmol/L Normal
Creatinine 30 _ 47 umol / L 38 umol /L Normal
BUN 6.3 mmol/l 3.2 _ 8.2 mmol/L Normal
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

B. Diagnostic Procedures

Diagnostic Studies & Procedure Results/Findings

ECG Normal sinus rhythm with non-specific ST changes in inferior

leads.

X-ray for: ___________________

____________________________ Nill

CT Scan for: _________________

____________________________ Nill

Ultrasound for: _______________

____________________________ Nill

MRI for: ____________________

____________________________
Nill

Other Special Procedures

 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

Fluid Intake and Output

Intake Output
Time Amount
Parenteral Oral Amount (ml) Urine Others
(ml)
8 am Water 200 1000

N/s 1000 cc Juice 100 Sweat 100 50

Other drugs 200 ml

2 pm

Shift Total Intake= 1500 Shift Total Output=1150

Nursing Care Plan (NCP) 6 SCORES

 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

Nursing
Patient-
Diagnosis
Assessment Centered Nursing interventions Rationale Evaluation
(in priority
Goals
order)
Subjective Data: Ineffective Short Term 1. Monitor distal 1. Absent or weak pulses After of
tissue pulses frequently. may indicate a nursing
Shortness of perfusion After 2 hours 2. Monitor the color, compromise in perfusion. intervention
breath related to of nursing temperature, and 2. Pallor, cyanosis, or The pt reports
A feeling of hypotension intervention sensation of all mottled skin color indicate of normal vital
impending evidenced the Patient extremities a blockage in perfusion to signs no
doom/death by excessive will 3. Monitor the the extremity. Demonstrates
Dizziness/ blood loss Demonstrate client’s oxygen 3. The major risk of adequate
lightheadedness/ vital signs saturation levels. hemorrhage is tissue
fatigue. within the 4. Perform frequent hypovolemic shock, which perfusion as
Objective Data normal range. neuro checks on interrupts blood flow to evidenced by
Patient is Long Term the patient. body cells palpable
lethargic, , has Goal: 5. Keep the head of 4. Blood loss reduces the peripheral
dry lips. the bed flat or less number of oxygen- pulses, warm
Weak/absent After 6 hours than 30 degrees carrying red blood cells and dry skin,
peripheral pulses of nursing 6. Note capillary refill leading to decreased adequate
Cool skin intervention time. oxygenation of organs, urinary
temperature Demonstrates 7. Provide adequate especially the brain output, and
Prolonged adequate oxygenation as 5. This position maximizes the absence of
capillary refill tissue ordered. cerebral perfusion. respiratory
Dysrhythmia/ perfusion as 8. Administer fluids as 6. Pale nail beds are not distress
Bradycardia/ evidenced by ordered. necessarily indicative of a
Tachycardia palpable blood flow occlusion but
Hypoxia peripheral poor perfusion.
pulses, warm 7. Supplemental oxygen
and dry skin, might be required to keep
adequate oxygen saturation greater
urinary than 90% and ensure
output, and adequate gas exchange.
the absence of 8. . Restrictive crystalloid
respiratory resuscitation (1-2 ml of
distress crystalloid for every 1 ml
of blood loss) as initial
resuscitation is
recommended according
to the clinical condition
and the estimated blood
loss.
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here]
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الجراحة الطبية‬

Patient-Centered Nursing
Assessment Nursing Diagnosis Rationale Evaluation
Goals interventions
Subjective Data: Deficient Fluid Short Term Independent: Changes in vital After of nursing
- Complains about Volume related After 3 hours of Monitor the signs intervention
an inability to focus to Excessive blood nursing intervention vital signs. accompanying the goal was met
- Complains of loss evidenced by the patient will Ensure bleeding include the patient
headaches trauma To stop maintain fluid hemodynamic decreased pulse displayed normal
- Describes feeling of bleeding, tachycardia, volume at a stability pressure, range of vital signs
fast heartbeat hypotension functional level as Apply direct tachypnea, and no
. Objective Data evidenced by pressure to any tachycardia. hemorrhage
individually bleeding The nurse present
adequate wound. should closely
Altered mental haemoglobin, Lie the person monitor airway
status hematocrit down. If a limb patency and
Decreased blood laboratory results, is injured, raise circulation.
pressure/orthostasis stable vital signs, the injured area Oxygen should
Tachycardia above the level be applied if
Weak/thready Long Term: of the person’s necessary, and
peripheral pulses After 1 days of heart (if an IV line should
Flat neck veins – nursing intervention possible). be started to
Fever The patient will Dependent: transfuse
Patient is lethargic, , remain free from Administer crystalloids.
has dry lips. signs of bleeding intravenous to control
fluid or blood hemorrhage
product from visible
replacement. vessels and
apply reduce tissue
pneumatic viability.
splints or if the client is
antishock experiencing
garments respiratory
during patient distress from
transportation decreasing
to the hospitall blood volume.
Administer Excessive blood
oxygen by face loss require
mask. blood
Collaborative: transfusion and
Perform the intravenous fluid
blood replacement.
transfusion if
indicated.

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