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Nursing process format revised ,2016.docx
- 1. 1 Personal Details Marital Status:Nationality: Ethnic group: Language: Single Widowed Religion: Married Living common law Occupation(previous and current): Divorced Patient’s support 1. Name: 2. Name: Relationship: Relationship: Address: Tel No.: City: Sub city: Kebele: House no. Address: Tel No.: City: Sub city: Kebele: House no. 1. Health perception and Management pattern Subjective data Client’s statement about reason of admission: ________________ __________________________________________________ __________________________________________________ Significant others’ statement about reason of admission: ____________________________________________________ Substance use Type Unit /measurement Frequency Effect if not taken Remark Alcohol Khat Tobacco Others Health maintenance practice:_______________________________________________ ___________________________________________________ Past medical history Measures taken for the problem Nursing/Midwifery Comprehensive Client Assessment Format Please Complete or Affix Label ________________HOSPITAL Ward: ___________ Bed No.: _______ Medical diagnosis:____________________ Date of admission: ___________________ Time of admission: ___________________ Full Name:_________________________________ Age:_____ Sex:____ MRN: Address:- City: Sub city: Kebele: House no. - Tel. No.:__________________________________ Source of information:____________________ Source of referral: ________________________
- 2. 2 **Known allergies formedication: ____food:____Others: ____ Specify: ________ Last immunization (type and date): ________________ Understanding of Medication(what, how and why) Patient is taking before admission (incl. “over the count” Drug name Dose Freq. Drug name Dose Freq. 2. Nutrition and Metabolism pattern Subjective data Objective data Pattern of food intake Breakfast:Lunch: Dinner: Snacks: Others_____________________ Special diet _______________________________ Appetite: Normal Increased Decreased Average Fluid intake per day in ml: ______ Difficulty in chewing: Yes No Sore tongue: Yes No Difficulty in swallowing: Yes No Nausea: Yes No Vomiting: Yes No Abdominal pain: Yes No Antacid: Yes No Wt. gain: Yes No Wt. losing: Yes No History of weight gain:Yes No Cold intolerance: Yes No Hot intolerance: Yes No Wt: ______Ht:______BMI: ______MUAC ___ Skin Color: jaundice Pallor Erythema Central cyanosisPetechiae Other ______ Lesion: Macule Papule Vesicle NodulePostuleWheal Ulcer Creast scale Other________ Texture: Smooth and Soft Rough Thick Temperature: WarmExtremely warm Extremely cool other____ Moisture: Dry Wet Oily Turgor/skin pinch: Immediately Slowly Very Slow Any visible Wound Yes No If yes type of wound ______________ Location:________ length in cm:___width in cm: ___ Discharge Yes No If yes colour: ___________________ Odour: ___________________ Bilateral pitting edema Yes No Oral cavity Mucosa: Intact Yes NoPink Yes No Moist Yes No Dry Yes No Lesion Yes NoOthers ________ Teeth: malformation Yes NoDenture Yes No Dental caries Yes No Other __________ Tongue: PinkPale Dry Moist Lesions Intact
- 3. 3 3. Elimination pattern SubjectiveObjective Bowel habits Frequency: _____Color ________________ Pain: Yes No Consistency_________ Laxative: Yes No Enema: Yes No Hx of Bowel surgery Colostomy Yes No Illeostomy Yes No Bladder habit Frequency _______Amt____ml Color: ____ Pain:Yes No Hematuria:Yes No Incotinenance: Yes No Nocturia: Yes No Retention: Yes No Urinary Catheter: Yes NoType_______ Abdomen Contour/shape: Rounded FlatDistended Scaphoid Abdominal detention Umbilicus: ProtrusionInflamed Drainage Vein: Engorged and Prominent Vein : Yes No Bowel sound:<5/m5-30/m>31/m Abdominal Tenderness: Yes No Characterize___________ 4. Activity and exercise pattern Subjective Objective Daily Activities (any difficulties with :) Hygiene: Yes No cooking: Yes No House work: Yes No shopping: Yes No Eating Yes No toileting Yes No Dyspnea: Yes No During Minor activity During vigorous activity Chest pain:Yes No Stiffness: Yes No Weakness: Yes No Aching:Yes No Effect of illness on activity of daily living:_____________________________ ________________________________________________ ____________________________________________ Musculoskeletal: Grooming ________________________ Gait: Steady/Balanced Unsteady/Unbalanced Posture:____________ Extremity swelling:Yes NoSymmetrical: Yes No Range of motion : Normal for all joint Decreased Crepitus: Yes NoTone: Strong Weak Respiratory Thorax Shape: Normal funnel Barrel pigeon Symmetry: equal unequal Intercostals space: even and relaxed Bulging Retracting Tenderness: Yes No Breathing Pattern: regular irregular Difficulty:Yes No Respiratory rate________________
- 4. 4 Objective data Score Levelof dependence 0 Fully independent in personal care 1 Requires minimal intervention 2 Requires moderate intervention 3 Requires intensive intervention 4 Requires intensive intervention(fully dependent) Depth: Normal Deep shallow Adventitious sound_________________________ Cardiovascular Jugular vein distension Yes No Heart sound: S1:YesNoS2:Yes No Murmurs_____________ Blood pressure : Rt arm :______ Lt arm :______ Pulse Rate : ____ Rhythm : regular irregular Bilaterally equal Yes No Temperature(in 0 C): Axilary___ Oral_____Rectal___ 5. Rest and sleep pattern Subjective Objective Sleep time___________ Adequacy: Yes No Difficulty falling sleep: Yes No Sleep aid: Yes No Sleep medications: Yes No Change in sleeping pattern: Yes No Difficulty remaining sleep: Yes No What facilitate sleep________________________________ What hinders sleep ________________________________ Yawning: Yes No Short attention span: : Yes No Irritability : Yes No 6. Sexuality and reproductive pattern Subjective Objective Female Menstruation Date began: _______Lastcycle_________Length______ Gravida: ____ Para____ Abortion___ still birth______ Current Pregnancy:Yes No LNMP:_________EDD--------GA--------- Fertility: Fertileinfertile Male/Female Contraception: Yes No Undesirable side effects of contraceptives :_____________ Problem with Sexual activities:_____________ ____________________________________ Breast: Shape___________Symmetry___________ Nipple: erected flatInvertedDischarge:Yes No Masses: Present No mass Lymph node: Enlarged: Yes NoTenderness: Yes No Testicular exam Masses:Yes NoSwelling:Yes No Penile exam Mass: Yes No Growth: Yes No Lesion:_________ Discharge: Yes No Female Genetalia Swelling:Yes No Symmetry: symmetrical
- 5. 5 Effect of illnesson Sexual activities:________ __________________________________ STD/STI: __________________________________ Pain during intercourse: Yes No Burning during intercourse: Yes No Discomfort during intercourse: Yes No asymmetrical Discharge: Yes No Characterize __________________ Vaginal opening: Lesion _______Discharge_______Inflammation: Yes No 7. Cognitive and perceptual Subjective Objective Educational status:______________________________ Able to read __________Write __________________ Primary language:__________________________ Visual problemYes No explain ____________________________ Aids for vision: Yes No Hearing problemYes No explain __________________________ Aid for hearing:Yes No Taste problem Yes No explain ______________________________ Smelling problemYes No explain __________________________ Problem in sensation(skin)Yes No explain ___________________________________________________ Pain(any):Yes No Characterize if yes ____________ Ability to recall: Remote: Yes NoRecent: Yes No Ability to make decisions: Yes No Expression of feelings: ______________________ Ability to speak Yes No Ability articulate words Yes No Level of consciousness : Glasgow coma scale : _____________ Orientation to TPP:_____________________ Hearing : Tympanic Membrane: Intact Ruptured whisper test: respond unable to respond Visual acuity: OD_________OS:___________OU:____________ PERRLA: intact Bilaterally Non intact Skin : Sensations: Superficial: +Ve –V o Deep Pressure: +Ve –V o 2 Point discrimination: +Ve –V 8. Self-Perception and Self-concept pattern Subjective Objective What do you feel differently about yourself? __________________________ Perception of abilities:__________________________ Things frequently make you angry ,fearful or anxious :____________________________________________________________________ ___________________________________________________________________ Appearance(dressing and Hygiene):__________________ _______________________________________________________ Mood(expression): Nervous ____ relaxed ____ ______________________________________________________________ Speech: Pace of conversation: Appropriate inappropriate Tone of voice: Appropriate to the situations Inappropriate to situations
- 6. 6 11.Value and belief Subjective Cultural practice :Yes No Religious practice Yes No Familial traditions (yes no ) Would you like your religious leader to be contacted? Yes No 9. Coping and stress tolerance pattern Subjective Any big change that can Cause Stressor:________________ _______________________________________________________ Coping methods: _________________________________ ______________________________________________________ Support system: __________________________________ 10.Role and relationship Discharge Arrangements and Other Social Details Subjective Objective Role in family:_________________________________________________ Responsibility: ________________________________________________ Work role:________________________________________________ Social role:_________________________________________________ Level of satisfaction:__________________________________________ Effect of illness on roles:_____________________________________ Lives alone? Employee? Self employee? Ability to pay: YesNo Comments:____________ Communication between family members:____ ____________________________________________________________ ____________________________________________________________ Family visits: Yes No Yes No Comments: __________________________________________ Yes No Comments: __________________________________________ Yes No Comments: _________________________________________
- 7. 7 Signature of admittingnurse: ___________ Signature of the client: _____ Date:______________ Date :________________ Summary of subjective and objective data Summary subjective data Summary objective data
- 8. 8 Full name___________________________________ Age __Sex____ MRN:Tel. No.: Ward: Bed No.: Problem no Nursing diagnoses (problem) Date identified Signature and designation Date resolved Signature and designation
- 9. 9 Nursing /midwifery careplan Full name___________________________________ Age __Sex____ MRN: Tel. No.: Ward: Bed No.: Date and Time Pro ble m No Goals Expected outcomes Interventions Signa ture
- 10. 10 Full name___________________________________ Age __Sex____ MRN:Tel. No.: Ward: Bed No.: Date Identified and Time Probl em No Implementations Signature and Designation
- 11. 11 Nursing progress note(SOAP format) Progress report 1: Shift: Morning Afternoon Night Date___________ Time___ Signiture ______ Subjective: ____________________________________________________________________________ ___________________________________________________________________________________________ Objective: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Analysis/ Assessment: _____________________________________________________________________________ Plan: _________________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________________ Progress report 2:Shift: Morning Afternoon Night Date___________ Time____ Signiture ______ Subjective:____________________________________________________________________________________ _______________________________________________________________________________________________ Objective: ____________________________________________________________________________________________ _________________________________________________________________________________________________ ____________________________________________________________________________________________ Analysis/ Assessment: _____________________________________________________________________________ Plan: _________________________________________________________________________________________________ _______________________________________________________________________________________ _________________________________________________________________________________________ Progress report 3:Shift: Morning Afternoon Night Date___________ Time___ Signiture ______ Subjective:____________________________________________________________________________________ _______________________________________________________________________________________________ Objective: ____________________________________________________________________________________________ _________________________________________________________________________________________________ Analysis/ Assessment: _____________________________________________________________________________ Plan: _________________________________________________________________________________________________ _________________________________________________________________________________________