West Visayas State University

College of Nursing
La Paz, Iloilo City

I. VITAL INFORMATION

Name: Date of Interview:

Age: Informant:

Sex: Relationship to Patient:

Address:

Civil Status:

Date and Time Admitted:

Chief Complaint:

Ward:

Bed No.:

Allergies:

Religious Affiliation:

Physicians Initial:

Impression/Diagnosis:

Pre-op Diagnosis (optional):

Post-op Diagnosis (optional):

Surgical Operation Performed (optional):

Days Post-op (optional):

II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY

1. History of Present Illness

a. Usual Health Status

 b. Chronologic Story

c. Relevant Family History

d. Disability Assessment

2. Past Health Problems/Status

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 a. Childhood Illness

b. Immunization

c. Allergies

d. Accidents and Injuries

e. Hospitalization for serious illnesses

Medications:

3. Family History of Illness

4. Patients Expectations

a. What does he/she expect to occur during this hospitalization?

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 b. What does he/she expect regarding nursing care?

5. Patterns of Functioning

a. Breathing Patterns

Respiratory Problems:

Usual Remedy:

Manner of Breathing:

b. Circulation

Usual Blood Pressure:

Any history of chest pain, palpitations, coldness of extremities, etc:

c. Sleep Patterns

Usual bedtime:

Number of pillows:

Bedtime Rituals:

Problems regarding sleep:

Usual Remedy:

d. Drinking Patterns:

Kinds of Fluid in 24 hours/Amount in mL or Number of Bottles:

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 Kinds of fluids taken in 24 Amount in mL or Number in
Hours bottles

Total

e. Eating Patterns

Usual Food Taken Time

(quantify) (range)

Breakfast

Lunch

Dinner

Snacks

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 Food likes:

Food dislikes:

f. Elimination Patterns

1. Bowel Movement

Frequency:

Problems or Difficulties:

Usual Remedy:

2. Urination

Frequency:

Problems:

Usual Remedy:

g. Exercise:

h. Personal Hygiene

1. Bath

Type:

Frequency:

Time of Day:

2. Oral Care

Frequency:

Care of Dentures:

3. Shaving

Frequency:

4. Use of Cosmetics:

i. Recreation:
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 j. Health Supervision:

II.B.: CLINICAL INSPECTION

Date and Time taken:

II.B.1. Vital Signs:

T= PR =

BP = RR =

II.B.2. Height:

II.B.3. Weight:

II.B.4. PHYSICAL ASSESSMENT

General Appearance:

A. INTEGUMENTARY SYSTEM

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B. NEURO-SENSORY SYSTEM

C. RESPIRATORY SYSTEM
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D. CARDIOVASCULAR/CIRCULATORY SYSTEM

E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM

F. GENITO-URINARY SYSTEM

G. REPRODUCTIVE SYSTEM
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H. ENDOCRINE SYSTEM

I. MUSCULOSKELETAL SYSTEM

J. LYMPHATIC SYSTEM

K. HEMATOPOEITIC SYSTEM

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II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle information

2. Normal coping Patterns

3. Understanding of Present Illness

4. Personality Style:

5. History of Psychiatric Disorder:

6. Recent Life Changes or Stressors:

7. Major Issues Raised by Current Illness:

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8. Mental Status Examination

APPEARANCE

Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact Inappropriate makeup others: _______________

Description:

BEHAVIOR

Calm Appropriate Restless Agitated Compulsions

Unusual actions others: _______________

Description:

SPEECH

Appropriate Pressured Loose Association Loud Soft

Mute others: _______________

Description:

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried Anxious

Angry Hopeless others: _______________

Description:

THOUGHTS

Appropriate Low Self-Esteem Suicidal Ideations Hallucinations

Delusions Phobias others: _______________

Description:

ABILITY TO ABSTRACT
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 Impaired: YES NO

Description:

MEMORY

Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes:

Description:

ESTIMATED INTELLIGENCE

Below Average Average Above Average

CONCENTRATION

Able to focus Easily distractible

Able to subtract backwards by 7s from 100 correctly until number ___.

ORIENTATION

Person ___ Time ___ Place ___ Situation ___

JUDGMENT

Realistic decision making: YES NO

Description:

INSIGHT

Good Fair Poor

Description:

II.C. NURSING PROGRESS NOTES (On-going Appraisal)

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II.D. OTHER SOURCES OF DATA

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IV. TEXTBOOK DISCUSSION

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V. PROBLEM LIST

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