Professional Documents
Culture Documents
____________________________________ Date Submitted _____________________________________ NURSING ASSESSMENT I PATIENTS PROFILE Name Sex Religion Address Civil Status Occupation Age
HEALTH HABITS Frequency 1. Tobacco 2. Alcohol 3. OTC-drugs/ non-prescription drugs Amount Period/Duration
A. CHIEF COMPLAINTS
B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational responsibilities, affected diagnoses}.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth and developmental history, nutrition- for pedia)
FAMILY HISTORY WITH GENOGRAM Acquired Diseases: Hypercholesterolemia Kidney Disease Tuberculosis Alcoholism Drug Addiction Hepatitis A B C Others (pls. specify) Heredo- familial Diseases: Diabetes Heart Diseases Hypertension Cancer Asthma Epilepsy Mental Illness Rheuma/Arthritis Others (pls. specify)
2. Hospital Environment
E. SUMMARY OF INTERACTION
REVIEW OF SYSTEMS Name Vital Signs: Temperature Pulse Respiration Blood Pressure Date Height Weight Observation ____________________________________
1.GENERAL
2. HEENT
3. INTEGUMENTARY
4. RESPIRATORY
5. CARDIOVASCULAR
6. DIGESTIVE
7. EXCRETORY
8. MUSCULOSKELETAL
9. NERVOUS
10. ENDOCRINE
DRUG STUDY
Mechanism Of Action
Indication
Contraindication
Adverse Reaction
Nursing Responsibilities
NURSING ASSESSMENT II
Name Chief Complaint Impression/Diagnosis Date/Time of Admission Diet: Type of Operation (if any)
____
Sex
____
_ __
NORMAL PATTERN
BEFORE HOSPITALIZATION
INITIAL DAY 1
2.NUTRITIONAL- METABOLIC a. Typical intake(food, fluid) b. Diet c. Diet restrictions d. Weight e. Medications/supplement food
6. OXYGENATION a. Vital signs Temperature Respiratory rate Heart rate Blood pressure b. Lung sounds c. History of Respiratory Problems
7. PAIN-COMFORT a. Pain (location, onset, character, intensity, duration, associated symptoms, aggravation)
b. Comfort measures/Alleviation
c. Medications
9. SEXUALITY a. female (menarche, menstrual cycle, civil status, number of children, reproductive status) b. male (circumcision, civil status, number of children)
LABORATORY AND DIAGNOSTIC PROCEDURES DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION
DATE/TIME STARTED
DROP RATE
NUMBER OF HOURS
DATE/TIME CONSUMED
SUMMARY OF MEDICATION
DATE
Remarks
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN NAME ______________________________________________ CONDITION UPON DISCHARGE ___________ DATE OF DISCHARGE: ____________________ Nature: Home per request ( ) Discharge against medical advice ( )
1. MEDICATIONS
2. EXERCISE
3. DIET
4. HEALTH TEACHING
NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION