This document contains a nursing assessment form for a patient which collects information about the patient's profile, health habits, chief complaints, history of present and past illnesses, family health history, review of systems, lab results, intake and output, medications, and nursing care plan. It gathers clinical data about the patient to inform the nursing diagnosis and development of a customized plan of care.

1. 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
HEALTH HABITS
Frequency Amount Period/Duration
1. Tobacco
2. Alcohol
3. OTC-drugs/ non-prescription drugs
A. CHIEF COMPLAINTS
B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.

2. 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

3. 2. Hospital Environment
E. SUMMARY OF INTERACTION
REVIEW OF SYSTEMS
Name Date
Vital Signs: Height
Temperature Weight
Pulse Observation ____________________________________
Respiration
Blood Pressure

4. 1.GENERAL
2. HEENT
3. INTEGUMENTARY

5. 4. RESPIRATORY
5. CARDIOVASCULAR
6. DIGESTIVE
7. EXCRETORY
8. MUSCULOSKELETAL
9. NERVOUS
10. ENDOCRINE

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

7. NURSING ASSESSMENT II
Name Age ____ Sex ____
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

8. 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)
.

9. 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

10. 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)

11. LABORATORY AND DIAGNOSTIC PROCEDURES
DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

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

13. SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks

15. ANATOMY AND PHYSIOLOGY

16. PATHOPHYSIOLOGY

17. MEDICAL MANAGEMENT

18. NURSING MANAGEMENT

19. SURGICAL MANAGEMENT

20. 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

21. NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

23. NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

24. NURSING CARE PLAN
CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION