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RIZAL TECHNOLOGICAL UNIVERSITY

COLLEGE OF NURSING
Boni Avenue, Mandaluyong City
FORMAT FOR NURSING PROCESS
Introduction
Objectives
I.

BIOGRAPHIC DATA
Name:
Address:
Age:
Gender:
Religious Affiliation:
Marital Status:
Occupation:
Room and Bed Number:
Chief Complaint:
Provisional Diagnosis:
Attending Physician:

II.

NURSING HISTORY

A. HISTORY OF PRESENT ILLNESS


-

When symptoms started, was onset sudden or gradual, how often does problem occur?
Specific dates when problem was experienced
Exact location of disturbance
Characteristic of the complaint (intensity, quality)
Amount of discharge, mucus, blood, stool, urine or size of lesion
Activity in which client was involved when problem occurred
Phenomena/symptoms associated with the complaint
Factors that aggravate/alleviate the problem
Disability assessment (how problem interferes with clients daily life activities)

B. PAST HEALTH HISTORY


-

Childhood illness (chickenpox, mumps, measles, rubella, rubeola, streptococcal infections,


rheumatic fever)
Childhood Immunizations (dates if possible)
Allergies (drugs, animals, insects, food and type of reaction that occurs)
Accidents/injuries (how, when, where it occurred, type of injury, treatment received,
complications)
Hospitalizations (reasons, date, location of hospital, surgery performed, course of recovery,
complications)
Medications (currently used, over the counter medications)
Foreign travel (when, length of stay)

C. FAMILY HISTORY
-

Name and age of siblings and parents, current health state of each/cause of death if any.

Any heart disease, cancer, diabetes, kidney disease, hypertension, obesity, allergies, arthritis,
tuberculosis, jaundice, bleeding, ulcers, migraine, alcoholism in the family?

D. Maternal/Obstetrical History
E. Growth and Development/Milestone
III.

PATTERNS OF FUNCTIONING

A. PSYCHOLOGICAL HEALTH
1. Coping Patterns
o Who are the people significant to you?
o Who can and do you talk on a regular basis?
o How much time do you spend alone?
o How many people do you relate to each day?
o Do you go out with and see other people on a regular basis?
o Do you keep to yourself most of the time?
o Do you exercise regularly?
o What type of exercise?
o Do you have anyone to go to in times of need?
o What do you do to handle stressful situations in your life?
o

Note non-verbal communications (eye contact, gestures,


body language, tone of voice, affect)

2. Interaction Patterns
o Who are the people in your family?
o How do you usually express your feelings and though to others?
o What do you think about voicing your opinion or feelings to family? to friends?
o Do you find ways to blame others for some things you do?
o What do you do when others make plans that you arent particularly interested in?
o Who initiates activities with family? with friends?
o How do you feel about the way you interact with others?
o

Observe to whom the client speaks in the family.

3. Cognitive Patterns
o How much formal education have you had?
o Can you read?
o Did or do you have difficulty with school or learning new things?
o How do you learn best, how are you doing in school/at work?
o

Note verbal ability (concrete thought, simple sentences,


formal operational thought, complex sentences, vocabulary
used, ability to conceptualize).

4. Self Concept
o What is your highest weight?
o How do you feel about your weight and appearance?
o Have you had any physical alterations to your body?
o Was or is it difficult for you to accept those changes?
o How have those changes affected your relationships with family? Friends?

o
o
o
o
o
o

The way you look at yourself? How do you see yourself in relation to other people?
Better than? Equal to? Less than equal to?
What religion and social values were you raised with? Are you comfortable with those
beliefs and values now?
How do you express your thoughts and feelings to others? Are there some situations
when you dont? When?
What are your goals in the next five years? How do you plan to achieve them?
Describe some characteristics of the type of person you would most like to be. Do you
see yourself as that person? Is your description realistic to you?
Observe the nature of the clients clothes (loose, fitted, clean,
soiled). Does client shield or avoid touching or looking at a
certain area of the body? What is the nature of any scars,
deformed body parts or alterations in function? When does
the client interact with; what is the clients affect? How is
client groomed (hair, clothes, nails, teeth, skin).

5. Emotional Patterns
o What type of mood are you usually in?
o How do you express yourself during mood changes?
o Do your relations with others change with your moods? How?
o Are you satisfied with your usual mood?
o Are you satisfied with your behavior during mood changes?
6. Sexuality
o
o
o
o
o
o
o
o
o

How do you express yourself as a man/woman?


Has your health concern changed the way you express yourself as a man/woman?
What do you enjoy/not enjoy about being a man or woman?
Do you have any problems regarding what others want you to do as a man/woman
and what you want to do as a man/woman?
What is your occupation?
How has being a man/woman affected your work?
How do you show affection toward others?
How do you want others to show affection to you?
Observe the persons identity and role behaviors (dress,
gestures,
grooming, nonverbal
behavior, nature
of
interactions with others)

7. Family Coping Patterns


o How does your family handle stress?
o How does your family make decisions:
o Who has the last word?
o If someone in the family gets sick, who is the caretaker?
o What is your role or place in the family?
B. Socio Cultural Health
1. Cultural Patterns
o What social values were you brought up with? With ones are important to you
now?
o What are/were the traditions in your family? (family gatherings, celebration, head
of home, types of food eaten, religious activities, health care practices)

Which of these do you participate in?

Observe what type of clothes the client wears. How is the


hair groomed? Stylist?

2. Significant Relationship
o Who are the significant people in your life? Family? Friends?
o To whom do you feel closest? Why?
o How does your family get along as a whole?
o Is there any major conflict in your family?
o Who do you go to when you have a concern or need help?
o How is your family reacting to your health-related concerns? Do you accept
them? Are they supportive?
3. Recreational Patterns
o What do you do for fun?
o How do you feel leisure time?
o Do you have hobbies or interests outside of work?
o Do you have the resources to get involved with your interests?
o What do you know about your communitys recreation resources?
o How long has it been since you participated in any leisure activities?
o What do you think or feel about that?
o

Observe for any leisure materials in the environment


(books, craft materials, woodworking, sport equipment,
stereo, collections)

4. Environment
o What type of dwelling do you live in?
o Are you comfortable where you live?
o Do you feel you have enough space to yourself? Is your palce easy to move
around in?
o Are there sounds, noises, or odors in the environment that are concern to you?
o Do you have any pets? What kind?
o

Observe the appearance of dwelling in regard to safety,


orderliness, cleanliness, note steps, placement of rooms,
shower or tub, and availability, loose rugs; what are the
usual sounds, noises and odors of the environment.

o
o
o
o
o

Is your income adequate to meet your basic needs for housing and food?
What are your priorities when budgeting?
How do you plan to pay for health care services?
Do have any concerns about this?
Do you have health insurance or medicare coverage?

5. Economic

C. Spiritual Health
1. Religious Beliefs and Practices
o What era your religious practices?
o What is your involvement with church groups and communities?

Do you have religious practices or do you practice the same religion you grew up
with? If not do you feel any conflict about this?

2. Values and Valuing


o What things are important to your life?
o Which would you say were most important?
o How do you incorporate these things into your lifestyle? If not, are you
comfortable with this?
o How do you feel about the social morals you were brought up with? Does this
present any conflict for you internally or with your family?
o How do you see yourself in relation to society?
o What do you think about helping people you dont know? People you do know?
o

IV.
1.
2.
3.
4.
5.
6.

Observe the indicators or values in the environment


(orderliness, safety, cleanliness, upkeep of furniture,
belongings). The indicators of values in interactions with
others (open dialogue, praise for others, active listening,
touch). Observe for any books or pamphlets regarding
things valued by the client.

Activities of Daily Living


Activities
Nutrition
Elimination
Exercise
Hygiene
Rest and Sleep
Sexual Activities

Before Hospitalization

After

Hospitalization

Analysis

1. Nutrition
o What kind of food can and do you eat?
o How many meals do you eat per day?
o What is your knowledge of the four basic food groups?
o Whom do you eat with?
o Where do you eat your meals?
o How often do you eat at home? In restaurants?
o Do you take daily vitamins? With iron? With minerals?
o Any recent changes in diet or weight?
o Any increase or decrease in appetite?
o

Observe: are height and weight proportional? What is the texture of


hair? Condition of scalp? What is the condition of nails? Gums? Teeth?

Measure: three-day recall, height and weight, laboratory results (CBC,


electrolytes)

2. Elimination
o How often do you urinate and have bowel movements?
o What does your urine look like (clarity, color)?
o Do you have any burning or foul smell to your urine?
o What do your bowel movements look like (consistency, color)?

o
o

Do you need laxatives to have a bowel movement? Enemas?


Do you experience pain during bowel movement?

Observe: color and odor of urine, describe consistency and color of


stools

Measure: frequency and amount of urination, frequency of bowel


movements, amount and kind of laxatives, bulk agent, or enema used,
laboratory results (urine and stool)

3. Exercise
o What kinds of physical activity do you engage in?
o How long has it been since youve done them?
o What type of work do you do for a living?
o Are you satisfied with the amount of exercise you get each week?
o

Observe: tone of the clients


proportional? Is atrophy present?

muscle,

are

height

and

weight

Measure: duration of physical activity, length of time since client has


exercised

4. Hygiene
o Describe how you take care of your body.
o Do you prefer baths, showers, or sink baths?
o Morning or evenings?
o Do you use deodorant agents or cologne?
o How often do you brush your teeth? Floss?
o When did you last visit your dentist?
o

Observe clothing and hair. What is the condition of hair and scalp?
Observe appearance of teeth.

Measure: frequency of hygiene of oral care, date of last dentist visit

5. Substance Abuse
o Do you smoke cigarettes or cigars?
o What is your understanding of the effects of smoking?
o Do you inhale the smoke?
o Do you drink alcoholic beverages?
o Whom do you drink with?
o Do you drink alone?
o Do you smoke marijuana or use any tranquilizers or stimulants (coffee, tea, cola)?
o What is your understanding of the use of marijuana and drugs?
o Do you use drugs and alcohol at the same time?
o

Observe: persons nonverbal messages while smoking (jittery, quick


movements, slow, relaxed movements). Attention span. Ability to
understand spoken word, response time, note pupil dilation and
constriction, hand tremors.

V.

Measure: number of cigarettes or cigars per day, number of drinks per


day or week, frequency of use of marijuana or drugs, number of cups of
coffee, tea or cola, amount of marijuana or drugs used at one time.

Physical Assessment
Day: __________

A. Measurement
Weight
Height
B. Vital Signs
Temp
PR
RR
BP

Date: __________
Findings

Time: __________
Interpretation /
Analysis

Normal

Head-To-Toe Physical Assessment


Body Parts / Technique

Normal
Findings

Actual
Findings

Interpretation / Analysis

A. Head
1. Skull
(Palpation)
2. Scalp
VII.

Anatomy and Physiology

VIII.

Pathophysiology

IX.

Diagnostic, Laboratory Results and Procedures


____________________
Microscopic Exam
Normal
Values

Test

X.

Date__________

Result

Interpretation / Analysis

Drug Study

Generic/
Brand Name/
Dosage/ Route/
Frequency/
Duration

Classification

Mechanism
of Action

Indication

Contraindication

Side Effects/
Adverse
Reaction

Nursing
Consideration

XI.

Prioritization of the Problem

XII.

Nursing Care Plan

Assessment

XIII.

Nursing
Diagnosi
s

Analysis

Health Teaching
M Medication
E Exercise
T Treatment
H Health Teaching
O Outpatient Follow ups
D Diet
S Sanitation/Spirituality

XIV.

Evaluation

Planning

Intervention

Rationale

Evaluation