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West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City NURSING PROCESS INTENSIVE CARE UNIT I. VITAL INFORMATION

Name: Age: Sex: Address: Civil Status: Religious Affiliation: Educational Attainment: Allergies: Date/Time of Hospital Admission: Chief complaint: Ward: Bed/ Cubicle No.: Physicians initials: Impression/Diagnosis: Pre-op Diagnosis: Post-op Diagnosis: Surgical Operation Performed: Number of Days Post-op: II. CLINICAL ASSESSMENT A. NURSING HISTORY 1. History of Present Illness a. Usual Health Status

Date and Time of Interview: Informant: Relationship to Patient:

Date and Time of ICU Transfer: Reason for Transfer:

b. Chronologic Story

c. Relevant Family History

d. Disability Assessment

2. Past Health Problems/Status a. Childhood Illness

b. Immunizations Type 1st dose BCG DPT OPV MMR Hepa B Others Age 2nd dose Age 3rd dose Age Booster 1 Age Booster 2 Age

c. Allergies NONE d. Accidents and Injuries NONE e. Hospitalization for serious illness NONE f. Medications

3. Family History of Illness NONE 4. Patterns of Functioning a. Breathing Patterns Respiratory Problems: Usual Remedy: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.: c. Sleeping Patterns

Usual bedtime: Waking-up time: Number of pillows: Bedtime rituals: Problems regarding sleep: Usual remedy: d. Drinking Patterns: Type of Fluid Amount

Total amount in 24 hours: e. Eating Patterns Usual Food Taken Breakfast Time

Lunch

Snacks

Supper

Food likes: Food dislikes:

f. Elimination Patterns 1. Bowel Movement Bowel Movement: Urination: 2. Urination Frequency: Problems: Usual Remedy: g. Exercise:

h. Personal Hygiene

1. Bath Type: Frequency: Time of Day: 2. Oral Care Frequency: Care of Dentures: 3. Shaving Frequency: 4. Use of Cosmetics: i. Recreation:

j. Health Supervision:

II.B

PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle Information

2. Normal Coping Patterns

3. Understanding of Present Illness

4. Personality Style

5. History of Psychiatric Disorder

6. Recent Life Changes or Stressors

7. Major Issues Raised by Current illness

C. CLINICAL INSPECTION Date & Time Taken: Vital Signs Temperature: Pulse Rate: Height: Weight: C.1. Primary Survey Airway: Respiratory Rate: Blood Pressure:

Breathing:

Circulation:

Disability:

C.2. PHYSICAL ASSESSMENT General Appearance:

Integumentary System:

Neurologic System:

CRANIAL NERVE Cranial Nerve I (Olfactory)

HOW ELICITED Ask patient to close eyes. Test each nostril by asking patient to inhale deeply and identify objects being smelled.

NORMAL RESPONSE Identifies an odor on each side of the nose. Smell normally is decreased bilaterally with aging.

PATIENTS RESPONSE

Cranial Nerve II (Optic)

Ask patient to read a certain text at a distance of 14 inches for near vision and at a distance of 20 feet for distant vision. Examine vision acuity using a Snellen Chart

Able to read word/ text at a distance of 14 inches for near vision and at a distance of 20 feet for distant vision. Identifies the characters on the Snellen Chart. Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(vertical direction) Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(diagonal direction) Able to clench jaw. Able to feel cotton wisp stroked on face and respond by saying yes each time she feels the stimulus.

Cranial Nerve III (Occulomotor)

Ask patient to follow directions of the examiners index finger as it moves into the six cardinal fields. Assess pupils response to light.

Cranial Nerve IV (Trochlear)

Ask patient to follow directions of the examiners index finger as it moves into the six cardinal fields. Assess pupils response to light.

Cranial Nerve V (Trigeminal)

Ask patient to clench jaw. Stroke patients face lightly with a cotton wisp and instruct to respond by saying yes each time she feels the stimulus.

Cranial Nerve VI (Abducens)

Ask patient to follow directions of the examiners index finger as it moves into the six

Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(horizontal

cardinal fields. Assess pupils response to light. Cranial Nerve VII (Facial) Observe symmetry of facial expressions. Ask patient to frown, raise eyebrows, wrinkle forehead, close eyes and keep them closed against the examiners resistance, smile, show teeth, purse lips, and puff cheeks against resistance of examiners hand. Test tasting sensation. Instruct patient to identify taste being placed on tongue.

direction)

Facial expressions are symmetrical. Able to frown, raise eyebrows, wrinkle forehead, close eyes and keep them closed against the examiners resistance, smile, show teeth, purse lips, and puff cheeks against resistance of examiners hand.

Able to identify taste being placed on tongue.

Cranial Nerve VIII (Acoustic)

Perform Voice-Whisper Test. Ask patient to occlude one ear while you whisper a two-syllable word. Ask patient to repeat the word. Test on both ears.

Able to repeat whispered words.

Examine soft palate, uvula Cranial Nerve IX (Glossopharyngeal) movement and gag reflex. Assess patients ability to swallow. Cranial Nerve X (Vagus) Motor: Assess for rise of soft palate and uvula upon phonation. Depress a tongue blade on posterior tongue to elicit gag reflex. Note any hoarseness in voice. Have patient say ah. Observe for symmetric rise of uvula and soft

Present gag reflex. Able to swallow.

Soft palate and uvula rises bilaterally and symmetrically upon phonation.

palate.

Cranial Nerve XI (Spinal Accessory)

Instruct patient to turn head sideways against the resistance of examiners hand. Instruct patient to raise shoulders against downward resistance.

Able to turn head sideways and able to raise shoulders against resistance.

Cranial Nerve XII (Hypogossal)

Instruct patient to resist force exerted on the tongue.

Able to resist force exerted on tongue.

C. Respiratory System

D. Cardiovascular System

E. Gastrointestinal System

F. Genito-Urinary System

G. Reproductive System

H. Endocrine System

I. Musculoskeletal System

J. Lymphatic System

K. Hematopoeitic System

C.3. Mental Status Examination APPEARANCE Neat Clean Disheveled Erect Posture Good eye contact Description:

Poor Grooming Appropriate Make-up

BEHAVIOR Calm Appropriate Description:

Restless

Agitated

Compulsions

Unusual Actions

SPEECH Appropriate Description:

Pressured

Loose Association

Loud

Soft

Mute

MOOD/AFFECT Appropriate Labile Description:

Flat

Depressed

Worried

Anxious

Angry

Hopeless

THOUGHTS Appropriate Description:

Low Self-esteem

Suicidal Ideations

Hallucinations

Delusions

Phobias

ABILITY TO ABSTRACT Impaired: YES NO Description:

MEMORY Impaired recent memory: YES NO Impaired past memory: YES NO No. of objects able to remember after 5 min.: _____ Description:

ESTIMATED INTELLIGENCE Below Average Average Description:

Above Average

CONCENTRATION Able to focus Easily distractible Able to subtract backwards by 7s from 100 correctly until number _____. Description:

ORIENTATION Person:

Time: Place: Situation: Description:

JUDGMENT Realistic decision making: Description:

YES

NO

INSIGHT Good Description:

Fair

Poor

III. Schematic Diagram of Medical Diagnosis

IV. Date

DIAGNOSTIC TESTS Diagnostic Test Requested

Done

Invasive/Noninvasive

Rationale

A. Significance of Abnormal Results

V. Collaborative Management A. Summary of Significant Information Date Findings and Interventions

B. Progress Notes

Date
Time Nurses Progress Notes Time Doctors Orders

Date
Time Nurses Progress Notes Time Doctors Orders

Date
Time Nurses Progress Notes Time Doctors Orders

VI. Nursing Care Plan VII. Drug Study