Western Mindanao State University COLLEGE OF NURSING Zamboanga City

FORMAT FOR THE NURSING PROCESS

ASSESSMENT
A. PERSONAL DATA Name: Address: Age: Date of Birth: Sex: Marital Status: Ethnic Group: Occupation: Religion Affiliation: Educational Attainment: Dialect/Language Spoken: Admission Date: Admission Time: Chief Complaints: Medical Impression: PRE-HOSPITALIZATION ILLNESS A narrative section where the clients chief complaint is documented in the proper sequence of events. The chronological story includes the following items: When the symptoms started Whether the onset of symptoms was sudden or gradual If available, specific dates when the problem was experienced How often the problem occurs Exact location of the distress Character of the complaint Amount of discharge, mucus, blood, stool, or urine or size of lesion Activity in which the client was involved when the problem occurred PAST HISTORY Childhood illnesses Childhood immunization Allergies to drugs, animals insects or other environment agents and the type of reaction that occurs Hospitalizations for serious illness; reasons for the hospitalization, name of the hospital, name of the physician, dates surgery performed, course of recovery, and any complications. FAMILY HISTORY OF ILLNESS Reveals risk factors for certain diseases. This information should include the ages of siblings, parents, and grandparents, and their current state of health (or if they are deceased) the cause of death. B. NURSING HISTORY (11 FUNCTIONAL HEALTH PATTERNS) The following guide questions are not inclusive, you have to explore further as the need arises: 1. Health Perception Health Management Pattern a. How has your general health been? Past Illness? Present Illness? Family Health Status? b. What cause your illness? c. What have you done to solve your problem? d. Was the action effective? e. Most important things done to keep healthy? (include family folk if appropriate) f. Immunization Status (if appropriate) g. Include this table: Medication (Prescription/over the counter/ Herbal Medicines Dosage Last dose Frequency

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. Food or eating discomforts? Diet restriction? (Religious Belief)? e. Skin problems, lesions, and dryness? General ability to heal? f. Dental problems? g. Height? h. 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 other discharges? (Wound) e. Any device employed to control excretion? f. Use of laxatives or any 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. Factors which interfere with desired or expected pattern (Such as neuro-muscular deficits or compensation dyspnea or muscle cramping on exertion, and cardiac/pulmonary classification, if appropriate) e. Perceive ability for (Code for level) Feeding _____ Dressing _____ Toileting _____ Bathing _____ Grooming _____ Home Maintenance _____ General Mobility _____ Bed Mobility _____ Shopping _____ Cooking _____ 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/s 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 right time routine that the individual employs? 6. Cognitive Perpetual Pattern a. Hearing Difficulty? (Include hearing aid if there is any) b. Visions? (Eye glasses? Contact lenses? Allergies?) c. Any changes in memory lately? d. Any difficulty in hearing? e. Any discomfort? 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. Changes in the way you feel about yourself or your body? (Since illness started) d. Things that frequently makes 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 work? (School/College) i. If appropriate, include family income. Is the income sufficient for needs? j. Feel part of or isolated in neighborhood where residing? 9. Sexuality Reproductive Pattern a. How many children? History of Abortions? Stillbirths? Premature? b. Any change or problems in sexual relationship? c. Use of contraceptives? Problems? d. Females: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? e. Describe client to the 3 major component of human sexuality: 1. Reproductive Sexuality 2. Gender Sexuality 3. Erotic Sexuality 10. Coping Stress Tolerance Pattern a. How does the family cope in time of crises? b. Tense a lot of time? What helps? Use of any medicines/drugs? c. Any big changes in your life in the last year or two? d. When you have a big problem, how do you handle them? Successful in handling problems? 11. Value Belief Pattern a. What do you consider as the most valuable/important in life? b. Generally get things you like? Most important things? c. Is religion important in your life? Does this help you when a difficulty arises? d. Does illness/hospitalization interferes with any religious practices? e. Any things we have talked about that youd like to mention? f. Questions? 12. Growth/Development Miletones a. Theories: Erik Erikson, Sigmund Freud, Jean Piaget b. Gross Motor Skills c. Fine Motor Skills d. Play/Socialization Actual Observation (or as related by SO) Document Reading and Resources

C. HOSPITAL ASSESSMENT PAIN/COMPORT Subjective: Location: ____________________ Intensity (1-10): ____________________ Frequency: ____________________ Quality: ____________________ Duration: ____________________ Radiation: ____________________ Precipitating Factors: ____________________ How Relieved: ____________________ Objective: Facial Grimacing: ____________________ Guarding affected area: ____________________ Emotional response: ____________________ Narrowed focus: _____________________ HEALTH MAINTENANCE-PERCEPTION PATTERN Tobacco: [ ] None [ ] (Date __________) [ ] Pipe [ ] Cigar __________ 1 pk./day Alcohol: [ ] None __________ Type/amount _____/day _____/wk _____/month Other drugs: [ ] No [ ] Yes Type __________ Use __________ Allergies (drugs, food, tape, dyes): __________ Reaction:__________ ACTIVITY EXERCISE PATTERN SELF-CARE ABILITY 0 Independent 1 Assistive device 2 Assistance from others 0 Eating / Drinking Bathing Dressing Grooming Toileting Bed Mobility Transferring Ambulating Range of Motion Sit Stand Subjective: Limitation Imposed by condition: ____________________ Sleep: Hours ____________________ Naps: ____________________ Aids: ____________________ Insomnia: ____________________ Related to: ____________________ Rested upon awakening: ______________________ Objective: Observed response to activity: Cardiovascular: _____________________ Respiratory: ____________________ Mental Status: ____________________ Neuromuscular Assessment: ____________________ Muscle Tone: ____________________ Posture: ____________________ Tremor: ____________________ ROM: _____________________ Strength: ____________________ Deformity: ____________________ Others: ____________________ 3 Assistance from person and equipment 4 Dependent / Unable 1 2 3 4

NUTRITION / METABOLIC PATTERN Subjective: Usual diet (type) _____________________ Meals daily ____________________ Last meal/intake ____________________ Dietary pattern ____________________ Lost of appetite ____________________ Nausea / Vomiting ____________________ Heartburn indigestion ____________________ Related to ____________________ Allergy/ food intolerance _____________________ Mastication / Swallowing problems ____________________ Swallowing problems _____________________ Dentures: Upper __________ Lower __________ Previous dietary instruction: [ ] Yes [ ] No ______________________________________ Appetite: [ [ Normal [ ] Increased [ ] Decreased [ ] Decreased taste sensation [ ] Nausea [ ] Vomiting [ ] Stomatitis Objective: Weight __________ Height __________ Body Build __________ Skin Turgor __________ Swallowing difficulty (dysphagia): [ ] None [ ] Solid [ ] Liquids Dentures: [ ] Upper ([ ] Partial [ ] Full) [ ] Lower ([ ] Partial [ ] Full) With patient [ ] Yes [ ] No History of Skin / Healing Problems: [ ] None [ ] Abnormal healing [ ] Rash [ ] Dryness [ ] Excess perspiration ELIMINATION PATTERN Subjective: Bowel Habits: __________ Number of BMs per day __________ Date of Last BM ___________ [ ] Within Normal Limit [ ] Constipation [ ] Diarrhea ___________ [ ] Incontinence [ ] Ostomy: Type __________ Appliance __________ Self Care [ ] Yes [ ] No Character of Stool __________ Bladder Habits: [ ] Within normal Limits [ ] Dysuria ___________ [ ] Frequency __________ [ ] Nocturia __________ [ ] Urgency ___________ [ ] Hematuria___________ [ ] Retention __________ Characteristic of urine __________ Inconsistency [ ] No [ ] Yes [ ] Total [ ] Daytime [ ] Nighttime [ ] Occasional [ ] Difficulty delaying voiding [ ] Difficulty reaching toilet Assistive devices: [ ] No [ ] Intermittent catheterization [ ] Indwelling catheter [ ] External catheter [ ] Incontinent brief [ ] Penile implant [ ] Type __________ Objective: Abdomen tender __________ Soft / Firm __________ Palpable Mass __________ Size / Girth __________ Bowel sound __________

Hemorrhoids __________ Bladder palpable __________ Overflow voiding __________ Edema __________ COGNITIVE-PERCEPTUAL PATTERN Hearing: [ ] WNL [ ] Impaired ([ ] Right [ ] Left) Deaf ([ ] Right [ ] Left) [ ] Hearing Aid [ ] Tinnitus Vision: [ ] WNL [ ] Eyeglasses [ ] Contact Lens [ ] Impaired [ ] Right [ ] Left [ ] Blind [ ] Right [ ] Left [ ] Cataract [ ] Right [ ] Left [ ] Glaucoma [ ] Prosthesis [ ] Right [ ] Left Vertigo: [ ] Yes [ ] No Discomfort/Pain: [ ] None [ ] Acute [ ] Chronic [ ] Description Pain Management ___________________________________________ COPING-STRESS TOLERANCE / SELF PERCEPTION / SELF CONEPTION PATTERN Major concerns regarding hospitalization or illness (financial, self-care): ______________________ Major loss/change in past year: [ ] Yes [ ] No Subjective: Report of stress factors ____________________ Ways of handling stress ____________________ Financial concerns ____________________ Relationship status _____________________ Cultural factors ____________________ Feeling of helplessness ____________________ Hopelessness ____________________ Powerlessness _____________________ Objective: Emotional Status _____________________ Calm ___________ Anxious __________ Angry __________ Withdrawn __________ Fearful __________ Irritable __________ Restive __________ Euphoric __________ Observed physiologic response: ____________________ SEXUALITY / REPRODUCTIVE PATTERN Female: Subjective: Last Menstrual Period (LMP) _______________________ Menstrual problems [ ] Amenorrhea [ ] Dysmenorrhea [ ] Metrorrhagia [ ] Menorrhagic [ ] Pre-menstrual Syndrome [ ] others: (Specify) _____________________ Age at menarche ____________________ Length of cycle ____________________ Menopause _____________________ Vaginal discharge ____________________ Bleeding between period ____________________ Last Pap Smear ____________________ Monthly Self-Breast Exam: [ ] Yes [ ] No Sexual concerns R/T Illness: ____________________ Surgeries ____________________ Hormonal Therapy ____________________ Method of Birth Control ____________________ Objective: Breast Exam: _______________________ Vaginal lesions ____________________ Pregnancy: Obstetrical History G ______ P ______ A ______ L ______ AOG __________ LMP __________ Smoking: [ ] Yes [ ] No

Drug Abuse: [ ] Yes [ ] No Excessive Vomiting: [ ] Yes [ ] No History of: [ ] Heart Disease [ ] Bronchial Asthma [ ] Thyroidism [ ] Diabetes [ ] Anemia [ ] Hypertension POP __________ Weight __________ FT __________ FHT __________ Leopolds Maneuver ___________ Presentation __________ Diagnostic Results __________ Pregnancy Test ____________________ [ ] Albumin in Urine [ ] Sugar in Urine [ ] Protein [ ] Serum B hCG level [ ] Coagulation Profile Post-partum [ ] Laceration [ ] Episiorrhaphy [ ] Periniorraphy Male: Subjective: Penile discharge____________________ Prostate Disorder ____________________ Practice testicular self-exam ________________ Objective: Exam: Breast _______________ Penis ____________ Testicles: ____________________ ROLE-RELATIONSHIP PATTERN Subjective: Occupation: _____________________ Employment Status: [ ] Employed [ ] Short- term disability [ ] Long term disability [ ] Unemployed Support System: [ ] Spouse [ ] Neighbors / friends [ ] None [ ] Family in same residence [ ] Others __________ Family concerns regarding hospitalization: _____________________ Objective: Verbal / Non-verbal communication with family and significant: ______________________ Others ______________________ SAFETY Subjective: Allergies reaction / sensitivity: ____________________ Exposure to infectious diseases: ____________________ Previous alteration if immune system: ____________________ Cause: ____________________ History of sexuality transmitted disease Date/type: __________ Testing: __________ High Risk Behaviors ____________________ Blood transfusion: Number: __________ When: __________ Reaction: __________ Describe __________ Geographic areas live/visited: ____________________ Seat belt / helmet use ____________________ History of accidental injuries: ____________________ Fractures / discolorations: _____________________ Arthritis / unstable joints: ____________________ Back problems: ____________________ Changes in moles: __________ Enlarged Nodes: __________ Delayed healing: __________ Cognitive limitations: __________ Impaired vision and hearing: ____________ Prosthesis: __________ Ambulatory device: __________ Objective: Temperature: __________ Diaphoresis: ___________ Skin integrity: scars __________ rashes ___________ Lacerations __________ ulcerations __________ Ecchymosis __________ Blisters __________

Burns degree (percent) __________ drainage: __________ General strength __________ muscle tone: __________ Gait: __________ ROM: __________ Paresthesia / paralysis _____________ Results of culture: ____________________ Immune system testing: ____________________ Tuberculosis testing: __________ VALUE-BELIEF PATTERN Religion: [ ] Roman Catholic [ ] Protestant [ ] Jewish [ ] Islam Others ___________ Religious Restriction: [ ] No [ ] Yes ( specify) __________ Request Chaplain Visitation at this time: [ ] Yes [ ] No D. PHYSICAL ASSESSMENT 1. CLINICAL DATA Age [ ] Height __________ Weight __________(Actual/approximate) Temperature __________ Pulse __________ Strong [ ] Weak [ ] Regular [ ] Irregular [ ] Blood Pressure: Right arm [ ] Left arm [ ] Sitting [ ] Lying [ ] 2. COGNITIVE-EMOTIONAL Language Spoken: [ ] English [ ] Chavacano [ ] Tagalog [ ] Other __________ Ability to read English: [ ] Yes [ ] No Ability to communicate: [ ] Yes [ ] No Ability to comprehend: [ ] Yes [ ] No Level of anxiety: [ ] Mild [ ] Moderate [ ] Severe [ ] Panic Interactive skills: [ ] Appropriate [ ] Other __________ 3. RESPIRATION CIRCULATORY Rate: __________ Quality: _____ WNL [ ] Shallow [ ] Rapid [ ] Labored [ ] Other Subjective: Dyspnea (Related to) ____________________ Cough / Sputum ____________________ History of smoking __________ Pk./day _____ No. of years _____ Use of respiratory aids __________ Objective Respiratory rate: ________ Depth ________ Symmetry ____________________ Use of Accessory muscles __________ Nasal Flaring __________ Fremitus __________ Auscultation: Upper Rt. Lobe [ ] WNL [ ] Decreased [ ] Absent [ ] Abnormal sounds Upper Left Lobe [ ] WNL [ ] Decreased [ ] Absent [ ] Abnormal sounds Lower Rt. Lobe [ ] WNL [ ] Decreased [ ] Absent [ ] Abnormal sounds Lower Left lobe [ ] WNL [ ] Decreased [ ] Absent [ ] Abnormal sounds Right Pedal Pulse: [ ] Strong [ ] Weak [ ] Absent Left Pedal Pulse: [ ] Strong [ ] Weak [ ] Absent B/P Right: Lying __________ Sitting __________ Standing __________ B/P Left: Lying __________ Sitting __________ Standing __________ Pulse Pressure __________ Color / Cyanosis __________ Mucous Membrane __________ Lips __________ Nail beds __________ Conjunctiva Sclera __________ Diaphoresis ___________ 4. METABOLIC/INTEGUMENTARY Skin: Color __________ WNL [ ] Pale [ ] Cyanotic [ ] Ashen [ ] Jaundice [ ] Others ____________________ Temperature: __________ WNL [ ] Warm [ ] Cool Turgor: _____WNL [ ] Poor Edema: [ ] No Yes / Description / Location ____________________

Lesions: [ ] No Yes / Description / Location ____________________ Bruises: [ ] No Yes / Description / Location ____________________ Reddened: [ ] No Yes / Description / Location ____________________ Pruritus: [ ] No Yes / Description / Location ____________________ Tubes: Specify _____________________ Mouth: Gums: __________ WNL [ ] White Plaque [ ] Lesions [ ] Other Teeth: __________ WNL [ ] Other __________ Abdomen: Bowel sounds: [ ] present [ ] Absent 5. NEURO / SENSORY Subjective Fainting spells / dizziness ____________________ Headaches: Location ____________________ Frequency ____________________ Tingling / numbness / weakness ____________________ Eyes: Vision loss ____________________ Speech: [ ] Normal [ ] Slurred [ ] Garbled [ ] Expressive Aphasia Spoken Language: __________ Interpreter __________ Pupils: [ ] Equal [ ] Unequal Left: _____________________ Right: ____________________ Glasses: __________ Contacts __________ Hearing Aids __________ Reactive to light: Left: [ ] Yes [ ] No / Specify __________ Right: [ ] Yes [ ] No / Specify __________ Eyes: [ ] Clear [ ] Draining [ ] Reddened [ ] Other __________ Objective Mental Status: [ ] Alert [ ] Receptive Aphasia [ ] Poor historian [ ] Oriented [ ] Confused [ ] Combative [ ] Unresponsive [ ] Disoriented Time: __________ 6. MUSCULAR SKETAL Range of motion: [ ] Full [ ] Other _______________________ Balance and Gait: [ ] Steady [ ] Unsteady Hand Grasps: [ ] Equal [ ] Strong [ ] Weakness / Paralysis ([ ] Right [ ] Left) Leg Muscles: [ ] Equal [ ] Strong [ ] Weakness / Paralysis ([ ] Right [ ] Left) 7. CIRCULATORY Subjective History of hypertension: __________ Heart Trouble __________ Rheumatic Fever __________ Ankle/Leg Edema __________ Phlebitis: __________ Slow Healing __________ Claudication __________ Dysreflexia __________ Bleeding Tendencies __________ Palpitations __________ Syncope __________ Extremities: Numbness / Tingling __________ Cough / hemoptysis ____________________ Change in frequency / Amount of Urine ___________ Objective BP: Right and Left: Lying / Sit / Stand ____________________ Pulse Pressure __________ Ausculatory Gap __________ Pulses __________ Carotid __________ Temporal __________ Jugular __________ Radial __________ Femoral __________ Popliteal __________ Post tibial __________ Dorsalis Pedis __________ Cardiac: __________ Thrill __________ Heaves ___________ Heart Sounds: Rate __________ Rhythm __________ Quality __________ Friction Rub __________Murmur __________ Vascular Bruits __________ Jugular Vein Distention ____________________ Breath Sounds ___________ Extremities: Temperature __________ Color __________ Capillary Refill __________ Homans sign __________ Varicosities ____________________ Nail Abnormalities __________ Edema __________ Quality of Distribution of Hair __________ Trophic skin changes __________ Color: General __________ Musculo skeletal membranes: ___________

Lips __________ Nailbeds __________ Conjunctiva __________ Sclera __________ Diaphoresis __________ 8. HYGIENCE Subjective Activities of Daily Living: Independent: ___________ Dependent ( Specify ): Mobility __________ Feeding ____________________ Objective General Appearance: ____________________ Manner of dress: _____________________ Personal Habits: ____________________ Body Odor: _____________________ Condition of Scalp: ____________________ Presence of Vermin: ____________________ 9. DISCHARGE PLANNING Length of stay: ____________________ Date Information obtained: _____________________ Anticipated date of discharge: ______________________ Resources Available: Persons: ____________________ Financial: ____________________ Community: ____________________ Support groups ____________________ Socialization ____________________ Areas that may require alteration / assistance: ____________________ Food preparation: ____________________ Shopping ____________________ Transportation: ____________________ Ambulation ____________________ Medical / IV Therapy: ____________________ Treatments: ____________________ Wound Care ____________________ Supplies: ______________________ Self Care: ____________________ Home maker / Maintenance ____________________ Physical lay-out of home ____________________ Anticipated Changes in living situation after discharge: ____________________ Living Facility other than home _____________________ Referrals (date, source, service) _____________________ Social service_____________________ Rehabilitation Services ____________________ Dietary ____________________ Home Care ____________________ Resp / O2 ______________________ Equipment ___________________ Supplies ____________________ Others ____________________________________ E. PHYSICAL EXAMINATION CEPHALOCAUDAL Head: shape, hair, scalp Face: a. eyes d. oral cavity b. ears e. other parts of the face (forehead, cheeks, chin) c. nose Neck: throat and nape Chest and Breast: Back: Abdomen: Upper and Lower extremities Genitalia: a. Physiologic Examination 1. Central Nervous System Level of awareness Attention deficit Communication (verbal and non-verbal) Coordination (use of fingers in picking up pencils) 2. Special Senses

Auditory Perception Pupillary Perception Speech Perception Gustatory perception Visual perception Tactile perception Olfactory perception

3. Respiratory System respiratory rate, rhythm, depth, breath sounds 4. Cardiovascular System Heart rate, rhythm depth Blood pressure 5. Nutritional Status: skin, mucous membrane, nails, height, weight, body temperature 6. Elimination Status: color, amount, odor, consistency, and frequency. Stool, urine and perspiration 7. Motor Ability Status: gait, posture and body movements LABORATORY AND DIAGNOSTIC TEST RESULTS 8. Blood studies (CBC, hematocrit, hemoglobin, FBS, Blood urea) 9. Urinalysis 10. Fecalysis 11. Sputum 12. GI Series 13. X-rays 14. EKG/ECG 15. Others

Western Mindanao State University COLLEGE OF NURSING Zamboanga City

NURSING CARE PLAN LEVEL III RLE

I. Patients Profile: Eleven Functional Health Pattern: Physical Examination: II. Nursing Care Plan PLANNING Objective of care with evaluation criteria Problem Etilogy Utilizing Principles S M A R T Nursing Intervention Rationale Implementation Evaluation

Nursing Diagnosis

Promotive Care; Preventive Care; Independent, Dependent, Interdependent Functions; Curative; Rehabilitative

With documentation/ References use

Date

III.

Study of Illness Conditions System/Organ Involved Normal Functions Analysis

ASSESSMENT Cluster of Cues Subjective:

Illustrate Anatomy Objective:

Discuss Normal Physiology/ Developmental Characteristics

Relates normal physiology/Developmental Characteristics with the present condition

Western Mindanao State University COLLEGE OF NURSING Zamboanga City

HEALTH TEACHING PLAN LEVEL III RLE

I. II. III. Patients Profile General Objectives: Learning Needs: Objective Content Time Allotment Strategies Resources Evaluation

IV.

Drug Study Brand Name: Generic Name: Classification: Indications/Contraindication: Mechanisms of Action: Dosage/Frequency/Route: Actual Nursing Responsibilities: