MINDANAO STATE UNIVERSITY Iligan Institute of Technology College of Nursing NURSING HEALTH ASSESSMENT I

Student Name: ________________________ Date of Care: __________ Score: ____________ Area of Assignment: _____________________ Clinical Instructor: _______________________ DEMOGRAPHIC DATA Name: __________________________ Age: ________ Sex: ________ Status: _____________ Address: ________________________ Religion: ___________ Occupation: ________________ HEALTH HISTORY A. Chief complaint/s:

B. Impression/Admitting Diagnosis:

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation

and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities).

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious

disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition for pedia)

E. Heath Habits Kind 1. Tobacco 2. Alcohol 3. OTC drugs F. Family History with Genogram History of Heredo-familial diseases: ____ Cancer ____ Diabetes ____ Asthma Legend: ____ Hypertension ____ Cardiac Disease ____ Mental disorder ____ Others: ______________ G. Patients Perception Present Illness: Frequency Amount Period

Genogram (up to 3rd generation)

Hospital Environment:

H. Summary of Interaction

PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

NAME: _______________________________________ Vital Signs: Temperature: _______________ Pulse: _______________ Respirations: _______________ DATE: __________________________ Height: _______________ Weight: _______________ Blood Pressure: _______________

1. General 2. HEENT

3. Integumentary System 4. Respiratory System 5. Cardiovascular System 6. Digestive System 7. Excretory System 8. Musculoskeletal System 9. Nervous System 10. Endocrine System

11. Reproductive System

NURSING ASSESSMENT II
Name of Patient: _______________________________ Chief Complaints: ______________________________ Impression/Diagnosis: __________________________ Date of Admission: _____________________________ Type of Operation (if any): ___________________________________________ Age: ______________ Sex: ________________ Inclusive Dates: __________________________ Allergies: _______________________________ Diet: ___________________________________

Normal Pattern 1. Nutrition Metabolic a. Typical intake (food or fluid) b. Diet c. Diet restriction d. Weight e. Medication / Supplement food

Before Hospitalization

Initial

Clinical Appraisal Day 1 Day 2

2. Elimination a. Urine (frequency, color, transparency) b. Bowel (frequency, color)

3. Ego Integrity a. Perception of self b. Coping Mechanism c. Support Mechanism d. Mood / Affect

4. Neuro Sensory

a. Mental state b. Condition of 5

SUMMARY OF MEDICATION DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS

SUMMARY OF INTRAVENOUS FLUID DATE IV FLUID & VOLUME DROP RATE TIME STARTED TIME ENDED INDICATION

DIAGNOSTIC AND LABORATORY PROCEDURE/S PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATION NURSING RESPONSIBILITIES

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

DRUG STUDY
MEDICATION (include dosage, route & frequency) DRUG CLASSIFICATION INDICATION MECHANISM OF ACTION SIDE EFFECTS/ADVER SE REACTIONS NURSING RESPONSIBILITIE S CONTRAINDICATI ONS AND CAUTIONS

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NURSING CARE PLAN

Identified Problem: Nursing Diagnosis: CUES Objective cues:

OBJECTIVES Short term objective:

INTERVENTIONS

RATIONALE

EVALUATION

Subjective cues:

Long term objective:

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DISCHARGE PLAN
DRUG DOSAGE FREQUENCY ROUTE INDICATION

Medication

Exercise

Therapy

Health Teachings

OPD Visit

Diet

Spiritual

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MEDICAL/SURGICAL MANAGEMENT (IDEAL AND ACTUAL) IDEAL ACTUAL

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NURSING MANAGEMENT (IDEAL AND ACTUAL) IDEAL ACTUAL

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