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Revised 2019

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: ___________________________________

HABITS

Frequency Amount Period/Duration

1. Tobacco
2. Alcohol
3. OTC-drugs/ non-prescription drugs

A. CHIEF COMPLAINTS:

B. HISTORY OF PRESENT ILLNESS (HPI) {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 Disease Heart Diseases
Tuberculosis Hypertension
Alcoholism Cancer
Drug Addiction Asthma
Hepatitis A Epilepsy
B Mental Illness
C Rheuma/Arthritis
Others (pls. specify) Others (pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

2. Hospital Environment

E. SUMMARY OF INTERACTION
Physical Examination

Name: ____________________________________ Date: ______________


Chief Complaint upon Initial Assessment: _______________________________________ Height: _____________
Chief Complaint upon Final Assessment: ________________________________________ Weight: _____________
Initial Vital Signs: Temp: ______ RR: ______ PR: ______ O2Sat: ______ BP: ________ Pain Score: ________ BMI: _______________
Initial Assessment Final Assessment (Last Day)

GENERAL

HEENT

INTEGUMENTARY
RESPIRATORY

CARDIOVASCULAR

DIGESTIVE

EXCRETORY

MUSCULOSKELETAL
NERVOUS

ENDOCRINE

DRUG STUDY
BRAND NAME GENERIC Prescribed and Mechanism
NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
NURSING ASSESSMENT II

Name Age ____ Sex ____


Admitting Chief Complaint _________________________________
Impression/Diagnosis _____________
Date/Time of Admission Inclusive Dates of Care _ _
Diet: _____________________ Allergies _______ __
Type of Operation (if any) __________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

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,


consistency)

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:

(sight, hearing, smell, taste,

touch)
6. OXYGENATION

a. Vital signs

Temperature

Respiratory rate

Heart rate

Blood pressure

b. Lung sounds

c. History of Respiratory

Problems

7. PAIN-COMFORT

a. Pain (location, onset,


character, intensity,
duration,
associated symptoms,
aggravation)

b. Comfort
measures/Alleviation

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 STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks


ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM
Functions of the cardiovascular system
Blood circulates through a network of vessels throughout the body to provide individual cells with oxygen and nutrients and helps dispose of metabolic wastes.
The heart pumps the blood around the blood vessels.

Functions of blood and circulation:

1. Circulates OXYGEN and removes Carbon Dioxide.


2. Provides cells with NUTRIENTS.
3. Removes the waste products of metabolism to the excretory organs for disposal.
4. Protects the body against disease and infection.
5. Clotting stops bleeding after injury.
6. Transports HORMONES to target cells and organs.
7. Helps regulate body temperature

Blood vessels

ARTERIES

carry oxygenated blood away from the heart. They are thick hollow tubes which are highly ELASTIC which allows them to DILATE (widen) and constrict
(narrow) as blood is forced down them by the heart. Arteries branch and re-branch, becoming smaller until they become small ARTERIOLES which are
even more elastic. Arterioles feed oxygenated blood to the capillaries. The AORTA is the largest artery in the body, taking blood from the heart,
branching into other arteries that send oxygenated blood to the rest of the body.
CAPILLARIES
distribute the nutrients and oxygen to the body's tissues and remove deoxygenated blood and waste. They are extremely thin, the walls are only one
cell thick and connect the arterioles with the venules (very small veins).
VENULES
(very small veins) merge into VEINS which carry blood back to the heart. The vein walls are similar to arteries but thinner and less elastic. Veins carry
deoxygenated blood towards the lungs where oxygen is received via the pulmonary capillaries. The PULMONARY Veins then carries this oxygenated
blood back to the heart.
The Heart

The heart is a hollow muscular organ which beats over 100,000 times a day to pump blood around the body's 60,000 miles of blood vessels. The right side of
the heart receives blood and sends it to the lungs to be oxygenated, while the left side receives oxygenated blood from the lungs and sends it out to the tissues
of the body.

The Heart has three layers;

1. ENDOCARDIUM (inner layer)


2. EPICARDIUM (middle layer)
3. MYOCARDIUM (outer layer). The heart is protected by the PERICARDIUM which is the protective membrane surrounding it.

The heart has FOUR CHAMBERS, in the lower heart the right and left Ventricles, and in the upper heart the right and left Atria. In a normal heart beat the
atria contract while the ventricles relax, then the ventricles contract while the atria relax. There are VALVES through which blood passes between ventricle
and atrium, these close in such a way that blood does not backwash during the pauses between ventricular contractions. The right and left ventricles are divided
by a thick wall (the VENTRICULAR SEPTUM), babies born with "hole in the heart" have a small gap here, which is a problem since oxygenated and
deoxygenated can blood mix. The walls of the left ventricle are thicker as it has to pump blood to all the tissues, compared to the right ventricle which only
pumps blood as far as the lungs.
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN

NAME ______________________________________________ DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )

1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT


NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION