Mindanao State University

Iligan Institute of Technology

COLLEGE OF NURSING

ASSESSMENT FORM
Student: ________________________
Area of Assignment: ______________
Date Submitted: __________________

Score: ____________
Clinical Instructor: _________________

PATIENT PROFILE
Name: ________________________ Age:_____
Sex: _______ Status:_____________
Address: _________________________________________________ Religion: ___________

NURSING ASSESSMENT I
A. Chief complaints:

B. History of Present Illness (HPI) (location, onset, character, intensity, duration,

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

C. History of Past illness (previous hospitalization, injuries, procedures, infectious

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

D. Heath Habits
Frequency
1. Tobacco
2. Alcohol
3. OTC drugs/non-prescription drugs

Amount

Period

E. Family History with Genogram

Legend:

History of Heredo-familial diseases:

Cancer
_______
Diabetes
_______
Asthma
_______
Hypertension
_______
Cardiac Disease
_______
Mental disorder
_______
Others
_______
LEGEND:
}

Deceased
Male
Female
Patient

A&W

UK

Cause of Death Unknown

Age Unknown
Separated or Divorced

--

-?

F. Patients Perception of
Present Illness:

Hospital Environment:

G. Summary of Interaction

REVIEW OF SYSTEM
Name: _________________________________
Date: _____________________
Vital Signs
Temperature: __________
Pulse:
__________
Height: __________

Alive and Well

Gender Questionable

Respiration:
__________
Weight:__________
Blood Pressure:__________
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 of Patient: ______________________________
Age: __________ Sex: __________
Chief Complaints: _____________________________
Inclusive Dates of Care: ________________
Impression/Diagnosis: __________________________
Allergies: ____________________________
Date of Admission: _____________________________
Diet: ________________
Type of Operation (if any):

Normal Pattern

Before Hospitalization

Initial

1. Activities Rest
a. Activities
b. Sleeping pattern
c.

Rest

2. Nutrition Metabolic
a. Typical intake (food or
fluid)
b. Diet
c.

Diet restriction

d. Weight
e. Medication / Supplement
food

Normal Pattern

Before Hospitalization

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

4. Ego Integrity
a. Perception of self
b. Coping Mechanism
c.

Support Mechanism

d. Mood / Affect

5. Neuro Sensory
a. Mental sate
b. Condition of 5 sense:
(sight, hearing, smell,
taste, touch)

Initial

Normal Pattern

Before Hospitalization

Initial

6. Oxygenation and Vital signs

a. Respiratory rate
b. Pulse rate
c.

Heart rate

d. Blood pressure
e. Lung sounds
f.

History of respiratory
problems

7. Pain comfort
a. Pain (location, onset,
intensity, duration,
associated symptoms,
aggravation)
b. Comfort measure /
alleviation
c.

Medication

Normal Pattern

Before Hospitalization

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

Initial

status, number of children)

SUMMARY OF MEDICATION
Date

Medication

SUMMARY OF INTRAVENOUS FLUID

Date/Time Started

Intravenous Fluids
& Volume

Drop Rate

LABORATORY AND DIAGNOSTIC PROCEDURE

NAME OF PROCEDURE

RESULT

NORMAL VAL

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

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DRUG STUDY

Generic Name
Brand Name
Classifications

Prescribed and
Recommended
Dosage,
Frequency, and
route of
Administration

Mechanism of
Action

Indication

Contraindi

NURSING CARE PLAN

CUES

NURSING
DIAGNOSIS

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OBJECTIVE

INTERVENTION

DISCHARGE PLAN
Patients Name: ______________________________________________
Date of Discharge: ___________________________
Condition upon Discharge: _____________________________________
Nature: Home per request ( )
Discharge Against Medical Advice ( )

1. Medication

2. Exercise
3. Diet
4. Health Teaching
5. Schedule for Next Visit
6. Spiritual
7. Lifestyle
8. Referral

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MEDICAL MANAGEMENT
IDEAL

SURGICAL MANAGEMENT
IDEAL

NURSING MANAGEMENT
IDEAL

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