COLLEGE OF NURSING

Xavier University
Ateneo de Cagayan

II. FUNCTIONAL PATTERN

A. Nutritional/Metabolic Pattern

LEVEL IV NURSING ASSESSMENT

RECORD (WARD)
I. PATIENT'S PROFILE
Name of Patient: AB
Age: 40 y.o. Civil Status:
Diagnosis: Sigmoid Diverticulitis No Malignancy
Attending Physician: Dr. V
Date & Time of Admission: May 29, 2012 @ 5:45PM
Language/Dialect Spoken: Visaya Informat: AB
Temperature: 36.5
Pulse: 60bpm Respiration: 20cpm
Blood Pressure: 100/70mmHg
Ht: 54
Wt: 46 kg
Chief Complaints/for Hospitalization: Left lower quadrant pain

Married

HPI: 4 months PTA, sudden onset of LLQ pain. 1 month PTA, increase in
severity of abdominal pain prompted consult, with medication but with no
improvement after the course of medication, patient then referred for further
management hence admitted.
Food and Drug Allergies (pls. Specify):
Past Major Illness, Operations and Hospitalization:
Family Medical History:
( ) Heart Disease
( )Renal Disease
( ) Cancer
( ) Stroke
( ) Lung Disease
( ) Others
Others: GI tumor Paternal and Maternal

( ) Hypertension
( )Substances Abuse

Meal Pattern: Appetite

( ) Good
( )Fair
(/ )Poor
Appetite Changes
(/)Yes
( )No
Canges in Eating Habits:
(/)Yes
( )No
Weight loss/Gain: loss about 10kg Special Diet: clear liquids
Teeth: poor, unhealthy
Feeding: (/) Per Orem ( ) NGT ( ) OGT ( ) Others please specify_______
Comments/Nursing Problems Identified: normal wt is 56kg and loss about 10kg
B. Elimnation Pattern
Bladder:

(/)No difficulty
( ) Dysuria
( )Oliguria
( ) Stones
( ) Incontinence
( ) Nocturia ( ) Anunia
( ) UTI
Voiding:
( /)With toilet privelege
( )W/out toilet privilege
( /) Per Urinal
( ) Per diaper
( ) Per FBC
Comments/Nursing Problems Identified
Bowel:

( ) No difficulty
( ) Constipation
( ) Incontinence
( /) Others Specify: diarrhea
Stool:
Character: soft
Frequency: 3 x/day Amount: moderate
Comments/Nursing Problems Identified: color of stool is brown, no melena
C. Sleep/Rest Pattern
Sleep Difficulty
( ) No
(/) Yes Describe due to pain
Use Sleep Aids:
(/ ) No
( ) Yes
( ) Specify
CommentsNursing Problems Identified: patient sleeps at least 5hrs a day.
Interruptions are due to pain

D. Activity/Exercise (I=independent; A=w/ assistance; D=dependent)

Activities of Daily Living:
( I) Eating
(I ) Bathing (A ) Dressing
( I) Grooming (I )Toileting
(I ) Ambulating
Activity Level:
( ) Active
(/ ) Sedentary
Comments/Nursing Problems Identified: patient is experiencing body malaise
E. CognitivenPerception Pattern
Glasses:
( ) Yes
( /) No Contact Lens: ( ) No ( )Yes
Hearing Aids:
(/ ) No
( ) Yes,
( ) Left
( ) Right
Prothesis:
(/) No
( ) Yes,
( ) Left
( ) Right
Comments/Nursing Problems Identified:

Comments/ Nursing Problems Identified: patient stopped smoking when he got

married. He smoked for 11 years.
G. Pain
( ) No (/ ) Yes, (describe):
10/10, stabbing pain at left lower quadrant of abdomen
Present Pain Management: pain relieveer
Comments/Nursing Problems Identified: Patient asks for pain reliever everytime
he is in pain
H. Sexuality/Reproduction Pattern
Testicular/Prostate Problem ( ) NA
Birth Control: ( )NA
(/ ) No

( /) No
( ) Yes
( ) Yes, (specify)

F. Behavior Pattern (Coping/Values)

Behavior

( ) Relaxed
(/ ) Midly Anxious
( ) Moderately Anxious
( ) VeryAnxious
Current Use of Medication, specify: moriamin forte, metronidazole,
ciprofloxacin
Psychiatric Hictory: none
Subsance Abuse :
Tabacco:
(/ ) No ( ) Yes
Drugs: ( /)No
( ) Yes
Alcohol:
( ) No ( /) Yes occasionally, Anything as long as hard liquor
Cigarette:
( ) No (/ ) Yes 2packs/day, fortune

I. Role Relationship Pattern

Occupation: labourer
With whom does patient lives: immediate family
Anticipating to return home? (/)Yes ()No, (specify reason): he wants to rest
well Person(s) available to assist at home: wife

III. PHYSICAL ASSESSMENT

(Indicate subject and objective cuesfor abnormalites noted)
Subjective

Objective

A. Neurological Assessment
Alert and oriented to person, place and time
Pupils equally round & reactive to light
No Paresthesia or Paralysis of extremities
No difficulty in speech or swallowing noted
B. Respiratory Assessment
Resp. 12-22bpm at rest
Respiration quiet & regular
Breath sounds in both lung fields clear
Nailbeds &lips pink

25 cpm
pale nail beds

C. Cardiovascular Assessment
Regular apical pulse
Heart rate 60-100 bpm
No complaints of chest pain
No edema
D. Peripheral-Vascular Assessment
Extremities are pink, warm, & movable w/ in
Normal ROM
Peripheral pulses palpable. No edema
No complaints of numbness/ calf tenderness
E. Genitourinary Assessment
Volding w/out discomfort or difficulty
Urine clear, frequency with own patternAppetite
No unusual vaginal ofr penile irritation
Discharge noted
F. Musculoskeletal Assessment
Absence of joint swelling & tenderness
No evidence of inflammation

pale extremeties but warm to touch

Normal ROM of all joint

No muscle weakness
No complaints of back pain

luya jud ko

appears weak and needs assistance when

G. Integumentary Assessment
Skin Color with patients norm
skin warm, dry and intact
Decubiti / Burns present?
()Yes ()No

pale extremeties, slightly brown (Moreno) complexion

bloated abdomen, abdominal girth is 36in (usual 32in)

Pls. Complete Skin Assessment Record

Skin (Burns & Decubiti)
Site

Type

Size