Western Mindanao State University
Perceive ability for: [code for level]
College of Nursing
Zamboanga City
Format of Nursing Process
I. Assessment
A. Personal Data
Name:
Address:
Age:
Sex:
Status:
Occupation:
Educational Attainment:
Ethnic Origin:
Dialect/Language spoken:
Religion:
Chief complaint:
Medical impression:
B. Nursing history (11 functional health
patterns)
1. Health Perception – Health Management pattern
a. How was your general health been? Past
illness? Present illness? Family health
status?
b. What cause your illness?
c. What have you done to solve your
problems?
d. Was the action effective?
e. Most important things done to keep
healthy [ include family folk if appropriate]
f. Immunization status [if appropriate]
2. Nutritional – Metabolic Pattern
a. Typical daily food intake? [Describe] food
supplements?
b. Typical daily fluid intake [describe] time?
c. Weight loss? Gain? [amount]
d. Foods or eating discomforts? Diet
restriction? Religious beliefs?
e. Skin problems, lesions and dryness?
General ability to heal?
f. Dental problems? Height?
g. Food preferences, use of nutrients or
vitamin supplement?
3. Elimination Pattern
a. Bowel elimination pattern [describe]
frequency? Discomfort? Character?
b. Urinary elimination pattern [describe]
frequency? Discomfort? Character?
c. Excess perspiration? Odor problems?
d. Any discharges? [wound]
e. Any devise employed to control excretion?
f. Use of laxatives or aid for bowel
elimination?
4. Activity – Exercise Pattern
a. Sufficient energy for completing
desired/required activities?
b. Exercise pattern? Type? Regularity?
c. Spare time [leisure] activities? Child play
activities?
d.
Feeding ____ Dressing ____ Cooking
____ Bathing ____ Grooming
____Toileting ____ Home Maintenance
____ Shopping ____ General Mobility
____ Bed Mobility ____
Functional Level Code:
Level 0: full self-care
Level 1: requires use of equipment
or device
Level 2: requires assistance or
supervision from another person
Level 3: requires assistance or
supervision from another person
and equipment
Level 4: is independent and does
not participate
5. Sleep – Rest pattern
a. How many hours of sleep/rest per day?
b. Generally rested and ready for daily
activities after sleep?
c. Sleep onset problems? [Nightmares?
somnambulism? early awakening?]
d. Time of sleep? Awakening?
e. Aids to sleep such as medication or night
time routine that the individual employs?
6. Cognitive – perceptual Pattern
a. Hearing difficulty? [include hearing aid and
if there is any]
b. Visions? [Eyeglasses? Contact lenses?
Allergies?]
c. Any changes in the memory lately
d. Any difficulty in hearing?
e. Any discomforts? Pain? How do you
manage it?
7. Self-perception – self-concept pattern
a. How do you describe yourself? Moods/
perception towards self?
b. Changes in the body or things you can
do?
c. Change sin the way you feel about
yourself or your body? [ since illness
started]
d. Things that frequently make you angry?
[depressed? Anxious? What helps?]
e. Are you happy/contented about yourself?
8. Role-Relationship Pattern
a. Family structure? How many members in
the family? [How do you describe the
interpersonal relationship among family
members?] Language spoken?
b. Live alone? Family type?
c. How does the family usually handle
problems?
d. Who is the breadwinner?
e. Problems with children? Difficulty
handling?
f. How family feels [or others] about your
illness?
g. Belongs to social groups? Close friends?
Feel lonely [frequency]
 h. Do things generally go well with you at Back:
work [school/college] Abdomen:
i. If appropriate, include family income. Is Upper and Lower extremities:
the income sufficient for the needs? Genitalia:
j. Feel part of or isolated neighborhood a. Physiologic examination
where residing? 1. central nervous system
• Level of awareness
9. Sexuality – Reproductive Pattern • Attention deficit
a. How may children? History of abortions? • Communication [verbal and non-verbal]
Stillbirths? Premature?
• Coordination [ use of fingers in picking
b. Any change or problems in sexual
up pencils]
relationship?
2. special senses
c. Use of contraceptives? Problems?
d. Females: when menstruation started? Last • auditory perception
menstrual period? Menstrual problems? • pupillary perception
Para? Gravida? • speech perception
e. Describe client to the 3 major component • gustatory perception
of sexuality: • visual perception
=reproductive sexuality • tactile perception
= gender sexuality • olfactory perception
= erotic sexuality
3. respiratory system – rate, rhythm, depth,
breath sound
10. Coping – Stress Tolerance Pattern
4. cardiovascular system – rate, rhythm, blood
a. How does the family cope in times of
pressure
crisis?
5. nutritional status – skin, mucus membranes,
b. Tense a lot of time? What helps? Use of
nails, height, weight, body temperature
any medicines/drugs?
6. elimination status – color, amount, frequency,
c. Any big changes in your life in the last
consistency, odor of urine and stool and
year or two?
perspiration
d. When you have a big problem, how do you
7. motor ability status – gait, posture, body
handle theme? Successful in handling
movements
problems?
III. Laboratory and diagnostic test results
11. Health – Belief Pattern
1. blood studies ( CBC, hematocrit, hemoglobin,
a. What do you consider as the most
fast blood sugar, blood urea)
valuable/ important in life?
2. urinalysis
b. Generally get things you like? Most
3. fecalysis
important things?
4. sputum
c. Is religion important to your life? Does this
5. gastrointestinal series
help you when a difficulty arises?
6. x-rays
d. Does illness/hospitalization interferes with
7. ECG/EKG
any religious practice?
8. others
12. Others:
IV. Drug study
a. Any things we have talked about that
• Brand name
you’d like to mention?
b. Questions? • Generic name
• Classification
13. Growth/Development Milestone • Dosage and frequency, route of administration
a. Theories: Erik Erikson, Sigmund Freud, • Side effects and adverse reactions
Jean Piaget • Nursing responsibilities
b. Gross motor skills
c. Fine motor skills
d. Play/socialization

Actual observation (or as Document readings

related by the SO) and resources

II. Physical Examination

Head: shape, hair, scalp

Face: a. eyes b. ears c. nose d. oral cavity e.
other parts of the face (forehead, cheeks, and chin)
Neck: throat and nape
Chest and Breast: