Assessment Tool

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Mindanao State University Iligan Institute of Technology

DEPARTMENT OF NURSING

ASSESSMENT FORM
Student: ________________________ Area of Assignment: ______________ Date Submitted: __________________ Score: ____________ Clinical Instructor: _________________

PATIENT PROFILE Name: ________________________ Age:_____ Sex: _______ Status:_____________ Address: _________________________________________________ Religion: ___________

NURSING ASSESSMENT I A. Chief complaints: B. History of Present Illness (HPI) (location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities).

C. History of Past illness (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia).

D. Heath Habits Frequency 1. Tobacco 2. Alcohol 3. OTC drugs/non-prescription drugs Amount Period

E. Family History with Genogram Legend:

History of Heredo-familial diseases: Cancer _______ Diabetes _______ Asthma _______ Hypertension _______ Cardiac Disease _______ Mental disorder _______ Others _______

F. Patient’s Perception of Present Illness:

Hospital Environment:

G. Summary of Interaction

1

REVIEW OF SYSTEM
Name: _________________________________ Vital Signs Temperature: __________ Pulse: __________ Respiration: __________ Blood Pressure:__________ 1. General 2. HEENT 3. Integumentary 4. Respiratory 5. Cardiovascular 6. Digestive 7. Excretory 8. Musculoskeletal 9. Nervous 10. Endocrine Date: _____________________

Height: __________ Weight:__________ Observation: _________________________________________

2

NURSING ASSESSMENT II
Name of Patient: ______________________________ Chief Complaints: _____________________________ Impression/Diagnosis: __________________________ Date of Admission: _____________________________ Diet: ________________ Type of Operation (if any): Age: __________ Sex: __________ Inclusive Dates of Care: ________________ Allergies: ____________________________

Normal Pattern 1. Activities – Rest a. Activities b. Sleeping pattern c. Rest

Before Hospitalization

Initial

Clinical Appraisal Day 1

Day 2

2. Nutrition – Metabolic a. Typical intake (food or fluid) b. Diet c. Diet restriction d. Weight e. Medication / Supplement food

Normal Pattern

Before Hospitalization

Clinical Appraisal

3

3. Elimination a. Urine (frequency, color, transparency) b. Bowel (frequency, color)

4. Ego Integrity a. Perception of self b. Coping Mechanism c. Support Mechanism d. Mood / Affect

5. Neuro – Sensory a. Mental sate b. Condition of 5 sense: (sight, hearing, smell, taste, touch)

Normal Pattern 6. Oxygenation and Vital signs

Before Hospitalization

Initial

Clinical Appraisal Day 1

Day 2

4

a. Respiratory rate b. Pulse rate c. Heart rate d. Blood pressure e. Lung sounds f. History of respiratory problems

7. Pain – comfort a. Pain (location, onset, intensity, duration, associated symptoms, aggravation) b. Comfort measure / alleviation c. Medication

Normal Pattern 8. Hygiene and activities of daily living

Before Hospitalization

Initial

Clinical Appraisal Day 1

Day 2

5

9. Sexuality a. Female (menarche, menstrual cycle, civil status, number of children, reproductive status) b. Male (circumcision, civil status, number of children)

6

SUMMARY OF MEDICATION Date Medication Remarks

SUMMARY OF INTRAVENOUS FLUID Date/Time Started Intravenous Fluids & Volume Drop Rate No. of Hours Date/Time Consumed

7

LABORATORY AND DIAGNOSTIC PROCEDURE NAME OF PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

8

ANATOMY AND PHYSIOLOGY

9

PATHOPHYSIOLOGY

10

DRUG STUDY
Prescribed and Recommended Dosage, Frequency, and route of Administration

Generic Name Brand Name Classifications

Mechanism of Action

Indication

Contraindication

Adverse Reaction

Nursing Responsiblities

11

NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

12

DISCHARGE PLAN
Patient’s Name: ______________________________________________ Condition upon Discharge: _____________________________________ Date of Discharge: ___________________________ Nature: Home per request ( ) Discharge Against Medical Advice ( )

1. Medication

2. Exercise 3. Diet 4. Health Teaching 5. Schedule for Next Visit 6. Spiritual 7. Lifestyle 8. Referral

13

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