The document appears to be a nursing assessment form for a patient at Mindanao State University College of Health Sciences. It collects information about the patient's health history, current symptoms, vital signs, laboratory results, medications, and nursing care needs over multiple days of hospitalization or treatment. Key sections include patient identification, health habits, medical history, family history, review of body systems, and clinical monitoring.
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The document appears to be a nursing assessment form for a patient at Mindanao State University College of Health Sciences. It collects information about the patient's health history, current symptoms, vital signs, laboratory results, medications, and nursing care needs over multiple days of hospitalization or treatment. Key sections include patient identification, health habits, medical history, family history, review of body systems, and clinical monitoring.
The document appears to be a nursing assessment form for a patient at Mindanao State University College of Health Sciences. It collects information about the patient's health history, current symptoms, vital signs, laboratory results, medications, and nursing care needs over multiple days of hospitalization or treatment. Key sections include patient identification, health habits, medical history, family history, review of body systems, and clinical monitoring.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online from Scribd
The document appears to be a nursing assessment form for a patient at Mindanao State University College of Health Sciences. It collects information about the patient's health history, current symptoms, vital signs, laboratory results, medications, and nursing care needs over multiple days of hospitalization or treatment. Key sections include patient identification, health habits, medical history, family history, review of body systems, and clinical monitoring.
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as DOCX, PDF, TXT or read online from Scribd
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Mindanao State University
COLLEGE OF HEALTH SCIENCES
Marawi City
Name of Student_____________________________________ Clinical Instructor_________________________________
Area of Assignment___________________________________ Date Submitted___________________________________ NURSING ASSESSMENT I PATIENT’S PROFILE Name_______________________________________ Address__________________________________________________________ Age_______ Sex_________ Religion________________________ Civil Status______________________ Occupation________________________
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: Heredo-familial Diseases: Hypercholesterolemia _______ Diabetes ______ Kidney Diseases _______ Heart Diseases ______ Tuberculosis _______ Hypertension ______ Alcoholism _______ Cancer ______ Drug Addiction _______ Asthma ______ Hepatitis A _______ Epilepsy ______ B _______ Mental Illness ______ C _______ Rheuma/Arthritis ______ Others (pls. specify) _______ others (pls. specify) ______
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action DRUG STUDY
Prescribed dosage, Mechanism
BRAND NAME GENERIC frequency, route of Of Indication Contraindication Adverse Reaction Nursing Responsibilities NAME CLASSIFICATION administration Action NURSING ASSESSMENT II
Chief Complaint___________________________________________________ Impression/Diagnosis______________________________________________ Date/Time of Admission____________________________________________ Inclusive Dates of Care ___________________ Diet_____________________________________________________________ Allergies___________________________ Type of Operation (if any)___________________________________________
CLINICAL APPRAISAL NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL DAY 1 DAY 2
1. ACTIVITIES – REST
a. Activities
b. Rest
c. Sleeping Pattern
2. NUTRITIONAL METABOLIC
a. Typical intake(food, fluid)
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplement food 3. ELIMINATION
a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
transparency)
4. EGO INTEGRITY
a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
5. NEURO-SENSORY
a. Mental state
b. Condition of five senses:
(light, hearing smell, taste, touch) 6. OXYGENATION a. Vital signs Temperature Respiratory rate Heart rate Blood Pressure b. Lung sounds c. History of Respiratory Problems
c. Medications 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
status, number of children) LABORATORY AND DIAGNOSTIC PROCEDURES
DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STATED INTRAVENOUS FLUID AND VOLUME DROP DATE NUMBER OF HOURS DATE/TIME CONSUMED SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks
ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY PATHOPHYSIOLOGY MEDICAL MANAGEMENT NURSING MANAGEMENT SURGICAL MANAGEMENT DISCHARGE PLAN NAME_______________________________________________ DATE OF DISCHARGE___________________________ CONDITION UPON DISCHARGE_________________________________ Nature: Home per request ( ) Discharge against medical advice ( )
