Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student _____________________________________ 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
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Mindanao State UniversityCOLLEGE OF HEALTH SCIENCES
Marawi City
Name of Student _____________________________________ Clinical Instructor ____________________________________
Area of Assignment Date Submitted _____________________________________
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)
Name Age ____ Sex ____ Chief Complaint _________________________________ Impression/Diagnosis _____________ Date/Time of Admission 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. Medications/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)
LABORATORY AND DIAGNOSTIC PROCEDURES
DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN
NAME ______________________________________________ DATE OF DISCHARGE: ____________________
CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )