Nursing Process

I. Biographic Data Name: Address: Age: Marital status: Room and bed: Chief complaint: Provisional Diagnosis: Attending Physician:

II. Nursing History A. Past Health History 1. Childhood Illness 2. Immunizations 3. Allergies 4. Accidents 5. Hospitalization 6. Medications used or currently taken 7. Foreign travel (when, length of stay) B. History of Present Illness C. Family History D. Obstetric History (for OB cases only) E. Developmental History (for Pediatrics cases only)

III. Patterns of Functioning A. Psychological Health 1. Coping Patterns 2. Interaction Patterns 3. Cognitive Patterns 4. Self-Concept 5. Emotional Patterns 6. Sexuality 7. Family Coping Patterns Interpretation: Analysis:

B. Socio-Cultural Patterns 1. Cultural Patterns 2. Significant Relationships 3. Recreation Patterns 4. Environment 5. Economic Interpretation: Analysis: C. Spiritual Patterns 1. Religious Beliefs and Practices 2. Values and Valuing Interpretation: Analysis: IV. Activities of Daily Living ADL 1. Nutrition 2. Elimination Before During Hospitalization Hospitalization Interpretation and Analysis

3. Exercise 4. Hygiene 5. Substance Use 6. Sleep and Rest 7. Sexual Activity V. Physical Assessment Norms General Appearance 1. Posture/Gait 2. Skin color 3. Personal Hygiene/ Grooming 4. Nutritional Status 5. Age Appropriateness 6. Verbal Behavior 7. Non-verbal Behavior Measurement 1. Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood Pressure 5. Weight 6. Height Body Part (Technique used) Norms Actual Findings Interpretation and Analysis Actual Findings Interpretation and Analysis

VI. Laboratory and Diagnostic Examinations Results Date Procedure Norms Result Interpretation and Analysis

VII.

Medications, IV Infusions, Blood Transfusion, Treatment Given

Gener ic/ Trade Name Treatm ent/Inf usion

Dosage/ Frequen cy

Classifi cation

Indicatio n

Contraindica tion

Side Effe ct

Nsg. Responsibil ities

Classificatio n

Indication

Contraindic ation

Nsg. Responsibilities

VIII.

Pathophysiology

IX. Ecologic Model A. Hypothesis

B. Predisposing Factors 1. Host a. Age b. Sex c. Race d. Nationality e. Behavior f. Customs g. Heredity 2. Agent a. Mechanical b. Physical c. Chemical 3. Environment a. Physical b. Biologic c. Socio-economic C. Ecologic 1. 2. 3. 4. Model Lever Wheel Web Triangle

D. Analysis (with reference) E. Conclusion and Recommendations X. Prioritized List of Nursing Problems Date Nursing Problems Identified Cues Justification

XI. Nursing Care Plan Nursi ng Probl em Cues NAND A Analysis Goal/Objecti ves Nursing Interventio ns Rational e Evaluation

Scientific SMART Supplement (With Implication al Referenc Immediate Developmen e) Subj. Cause tal Intermediat Facilitative Obj. e Cause Root Cause Discharge Plan (to be submitted by students whose patients are for discharge) M Medications to take at home E Exercise T Treatments H Health Teachings O Out patient follow up D Diet S Sexual Activity (optional)

Effectiveness Efficiency Adequacy Appropriatene ss Acceptability