Salvador, Christian Joy Q.

BSN III-E19 NEURO WARD November 25, 2010

University of the East
Ramon Magsaysay Memorial Medical Center, Inc.
Aurora Boulevard, Quezon City
COLLEGE OF NURSING
NURSING PROCESS & NURSING CARE PLANS
I. Patient’s Profile
Name:
Age:
Birthday:
Gender:
Status:
Address:
Education:
Occupation:
Religion:
Date admitted:
Time admitted:
Attending Physician:
II. Health History

a. CHIEF COMPLAINT:
b. PRESENT HEALTH HISTORY:
c. PAST HEALTH HISTORY:
d. FAMILY HISTORY:
e. PSYCHOSOCIAL HISTORY:
f. DEVELOPMENTAL HISTORY:
Developmental Level:
g. ACTIVITIES OF DAILY LIVING

III. Physical Assessment

A. General Physical Survey
B. Skin, Hair, and Nail Assessment
C. Head and Neck Assessment
D. Eye Assessment
E. Ear Assessment
F. Nose and Sinuses Assessment
G. Mouth and Pharynx
H. Cardiac Assessment
I. Peripheral Vascular System Assessment
J. Thorax and Lung Assessment
K. Abdominal Assessment
L. Musculoskeletal Assessment
M. Neurologic Assessment

IV. Gordon’s Functional Pattern

1. Health Perception Management Pattern

S:
Salvador, Christian Joy Q. BSN III-E19 NEURO WARD November 25, 2010
O:
A:
2. Nutritional-Metabolic Pattern
S:
O
A:

3. Elimination Pattern
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A:
4. Activity-Exercise Pattern
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O:
A:

5. Sleep-Rest Pattern
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O:
A:

6. Cognitive-Sensory Pattern
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O:
A:

7. Self-Concept Pattern
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O:
A:

8. Role-Relationship Pattern
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O:
A:

9. Sexuality-Reproductive Pattern
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A:

10. Coping Stress-Tolerance Pattern

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A:

11. Value-Belief Pattern

Salvador, Christian Joy Q. BSN III-E19 NEURO WARD November 25, 2010
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A:

V. Pathophysiology
VI. Lab Findings
VII. Drug Analysis

GENERIC NAME SPECIFIC DOSAGE SPECIFIC INDICATION SIDE EFFECTS NURSING

RESPONSIBILITIES
o
BRAND NAME MECHANISM OF CONTRAINDICATION ADVERSE REACTION
ACTION
  o o
CLASSIFICATION
Salvador, Christian Joy Q. BSN III-E19 NEURO WARD November 25, 2010
Salvador, Christian Joy Q. BSN III-E19 NEURO WARD November 25, 2010
VIII. Nursing Care Plans
CUES NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S:
O:
VS: T-, P-, R-, BP-;