Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student _____________________________________________________ Area of Assignment __________________________________________________ NURSING

ASSESSMENT I PATIENTS PROFILE Name Sex Address Religion Age Civil Status Occupation Clinical Instructor __________________________________ Date Submitted ___________________________________

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, habits, birth and development history, nutrition- for pedia)

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Hypercholesterolemia Kidney Disease 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

NURSING ASSESSMENT II

Name _______________________________________________________ Chief Complaint ______________________________________________ Impression/Diagnosis _________________________________________ Date/Time ___________________________________________________ Diet ________________________________________________________ Type of Operation (if any) ______________________________________ NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL

Age __________________ Sex ____________________ Inclusive Dates of Care _____________________________ Allergies _________________________________________

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/Supplement food

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 five senses: (sight, 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)

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

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

DRUG STUDY Generic Name Brand Name Classification Prescribed, Recommended Dosage, frequency, And route of administration

Mechanism of Action

Indication

Contradiction

Adverse Reaction

Nursing Responsibilities

NURSING MANAGEMENT

MEDICAL MANAGEMENT Ideal Actual

UA

SURGICAL MANAGAEMENT

PATHOPHYSIOLOGY

ANATOMY AND PHYSIOLOGY

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