NURSING PROCESS GUIDELINES

I. ASSESSMENT
A. General Data

Patient’s Initials:
Address: (generic-not complete) Informant:
Age: Date of Admission:
Sex: Order of Admission:
Date of Birth: No. of days in the Hospital:
Place of Birth: Date of History: (date & time)
Civil Status:
Occupation:

B. Chief Complaints

(Problem with the duration and accompanying signs and symptoms, one or more symptoms or concerns
causing the patient to seek care or may quote the patient’s own words.)

C. History of present illness

(Complete, clear, and chronologic account of the problems prompting the patient to seek care. Onset &
manifestations, reason why patient sought consultation; include medication taken.)

D. Past History

1. Childhood Illness/es (ex. Asthma)

2. Adult Illness/es
3. Immunization (date)
4. Previous Hospitalization (date)
5. Operation/s (include year)
6. Injuries (include year)
7. Medications taken prior to confinement (for 3 yrs and above)
8. Allergies

E. System Reviews- Gordon’s Eleven Functional Areas (more than 3 yrs. Old only)

1. Health perception – Health management

2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity & Exercise
5. Cognitive – Perceptual
6. Sleep – Rest
7. Self –perception
8. Role – Relationship
9. Sexuality – Reproductive
10. Coping/Stress Tolerance
11. Values/Beliefs

F. Family Assessment

Name Relation Age Sex Occupation Educational Attainment

G. Heredo- Family Illness

Maternal:
Paternal:

H. Developmental History

Theorist Age Sex Patient Description

I. Physical Examination (indicate date and time of examination)

Height: Actual Weight:

Actual Height: Ideal Body Weight:

Anthropometric measurement: (for pedia 0 - 3 years old)

Head Circumference:
Chest Circumference:
Abdominal Circumference:

Vital Signs:

T:
 PR:
RR:
BP:

Regional Examination

A. Skin
I: (color, lesions, symmetry, abnormalities)
P: (temperature, turgor, moisture, type of skin, masses, tenderness)

B. Nails
I: (color, shape, angle, abnormalities)
P: (capillary refill, nail plate surface)

C. Head and Face

I: (color of hair and skin, alopecia, hair distribution, size, shape of face, symmetry,
lesion,(its location), abnormalities,)
P: (hair surface, masses, tenderness)

D. Eyes
I: (size, shape, symmetry, color, location, abnormalities)
P: (masses, tenderness, and test for EOM, direct and consensual, convergence,
accommodation, visual acuity, visual fields)

E. Ears
I: (size, shape, symmetry, color, location, abnormalities)
P: (masses, tenderness, test for rinne’s, weber’s and whisper test)

F. Nose
I: (size, shape, symmetry, color, location, abnormalities, discharges’ characteristics)
P: (masses, tenderness, test for potency)

G. Mouth and Pharynx

I: (size, shape, symmetry, color, location, abnormalities, odor)
P: (masses, tenderness, gag reflex)

H. Neck
I: (size, shape, symmetry, color, location, abnormalities, lesions)
P: (masses, tenderness)

I. Spine
I: ( shape, symmetry, location, abnormalities)
P: (masses, tenderness)

J. Thorax/Lungs
I: (size, shape, symmetry, color, location, abnormalities, body type)
P: (masses, tenderness, test for tactile fremitus and chest excursion)

K. Cardiovascular/Heart
I: (skin lesion, abnormalities)
Pa: (masses, tenderness)
Per: (6 auscultatory areas)
A: (heart sound)

L. Breast
I: (size, shape, symmetry, color, location, abnormalities)
A: (lung sound)
P: (masses, tenderness)

M. Abdomen
I: (size, shape, symmetry, color, location of the umbilicus, abnormalities)
A: (bowel sounds)
Per: (size and location of the organs)
Pa: (masses, tenderness)

N. Extremities
I: (size, shape, symmetry, color, location, abnormalities)
P: (masses, tenderness)

O. Genitals
I: (color, location, abnormalities, lesions, odor)
P: (masse/nodules, tenderness)

P. Rectum and Anus

I: (size, shape, symmetry, color, location, abnormalities, odor)
P: (masses/ nodules, tenderness)

Q. Neurologic Exam (complete LOC, gait and posture, attitude, vocabulary, physical appearance)

II. PERSONAL / SOCIAL HISTORY

 Habits: Rank/order in the family:
Vices: Travel (for the last 6 mos. Only):
Lifestyle: Educational Attainment:
Social Affiliation: (organization)
Client’s usual day like:

III. ENVIRONMENTAL HISTORY

IV. OB / GYNE HISTORY

*FOR FEMALES ONLY (based from the client – N/A if not applicable)

Menarche (age) ___________ When: ______________________________

Amount and Characteristics:_____________
Duration:____________________________
Associated Symptoms: _________________

Deliveries: G_____________ P_____________ Operations_____________

OB Score: T___________ P___________ A___________ L____________

V. PEDIATRIC HISTORY

MATERNAL AND BIRTH HISTORY

Birth date: Hospital:

Birth Weight:
Type of delivery:
Condition after birth:

*Mother:
Complications of delivery:
Anesthesia during labor:
Exposure to Teratogenic Agents during Pregnancy:

*Neonates:
Neonatal History:
Feeding History:
Type of Feeding:

VI. PATHOPHYSIOLOGY (diagram form)

A. Theoretical Based (indicate reference)
B. Client Based

VII. LABORATORY RESULT AND FINDINGS

Laboratory (date) Normal Value Result Interpretations/

Significance

VIII. DRUG STUDY (client based)

Drugs Indication Action Side effects/ Adverse Nursing Patient

Reaction Consideration Teaching
Date Ordered:
Generic Name:
Brand:
Classification:
Dosage:

IX. LIST OF PRIORITY PROBLEMS

X. NURSING CARE PLAN

Cues / Nursing Rationale Goals and Interventions Rationale Evaluation

Needs Diagnosis Objectives
Subjective (Problem and (indicate Independent: (based from the
Data: Etiology) source) book: indicate
Dependent: the book,
Objective author, page,
Data: Collaborative: year/ed.)

XI. ONGOING APPRAISAL

A comprehensive summary of patient’s health status to include medication, procedures. Laboratory done
in collaboration with other members of the Health team.

XII. DISCHARGE PLAN

M – Medication
E – Exercise
T – Treatment
H – Health Education
O – OPB follow - up
D – Diet
S – Signs and Symptoms