Mindanao State University Iligan Institute of Technology
DEPARTMENT 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 _______
F. Patients Perception of Present Illness:
Hospital Environment:
G. Summary of Interaction
REVIEW OF SYSTEM
Name: _________________________________ Vital Signs Temperature: __________ Pulse: __________ Respiration: __________ Blood Pressure:__________ 1. General 2. HEENT 3. Integumentary 4. Respiratory 5. Cardiovascular 6. Digestive 7. Excretory 8. Musculoskeletal 9. Nervous 10. Endocrine Date: _____________________
Height: __________ Weight:__________ Observation: _________________________________________
NURSING ASSESSMENT II
Name of Patient: ______________________________ Chief Complaints: _____________________________ Impression/Diagnosis: __________________________ Date of Admission: _____________________________ Diet: ________________ Type of Operation (if any): Age: __________ Sex: __________ Inclusive Dates of Care: ________________ Allergies: ____________________________
Normal Pattern 1. Activities Rest a. Activities b. Sleeping pattern c. Rest
Before Hospitalization
Initial
Clinical Appraisal Day 1
Day 2
2. Nutrition Metabolic a. Typical intake (food or fluid) b. Diet c. Diet restriction d. Weight e. Medication / Supplement food
Normal Pattern
Before Hospitalization
Clinical Appraisal
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)
Normal Pattern 6. Oxygenation and Vital signs
Before Hospitalization
Initial
Clinical Appraisal Day 1
Day 2
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 8. Hygiene and activities of daily living
Before Hospitalization
Initial
Clinical Appraisal Day 1
Day 2
9. Sexuality a. Female (menarche, menstrual cycle, civil status, number of children, reproductive status) b. Male (circumcision, civil status, number of children)
SUMMARY OF MEDICATION Date Medication Remarks
SUMMARY OF INTRAVENOUS FLUID Date/Time Started Intravenous Fluids & Volume Drop Rate No. of Hours Date/Time Consumed
LABORATORY AND DIAGNOSTIC PROCEDURE NAME OF PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
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DRUG STUDY
Prescribed and Recommended Dosage, Frequency, and route of Administration
Generic Name Brand Name Classifications
Mechanism of Action
Indication
Contraindication
Adverse Reaction
Nursing Responsiblities
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NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
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DISCHARGE PLAN
Patients Name: ______________________________________________ Condition upon Discharge: _____________________________________ Date of 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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