Nursing Process Adult
17
QuickTime™ and a decompressor are needed to see thi West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING PROCESS 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: Physician’s Initials: Impression/Diagnosis: Pre-op Diagnosis: Post-op Diagnosis: II. CLINICAL ASSESSMENT
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Transcript of Nursing Process Adult
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West Visayas State UniversityCOLLEGE OF NURSING
La Paz, Iloilo City
NURSING PROCESS
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:
Physician’s Initials:
Impression/Diagnosis:
Pre-op Diagnosis:
Post-op Diagnosis:
II. CLINICAL ASSESSMENT
II.A. NURSING HISTORY
II.A.1. History of Present Illness
a. Usual Health Status
b. Chronologic Story
c. Relevant Family History
d. Disability Assessment
II.A.2. Past Health Problems
a. Childhood Illnesses
b. Immunizations
c. Allergies
d. Accidents and Injuries
e. Hospitalizations
f. Medications
II.A.3. Family History of Illness
II.A.4. Patient’s Expectations
a. What he expects to occur during this hospitalization?
b. What he expects regarding nursing care?
II.A.5. Patterns of Functioning
a. Breathing Patterns Respiratory Problems:
Usual Remedy:
Manner of Breathing:
b. CirculationUsual Blood Pressure:
Any history of chest pain, palpitations, coldness of extremities, etc.:
c. Sleeping PatternsUsual Bedtime:
Number of pillows:
Bedtime Rituals:
Problems regarding sleep:
Usual remedy:
d. Drinking Patterns
Kinds of Fluid Taken Amount
Total Amount
e. Eating Patterns
Food Taken Time
Breakfast
Lunch
Snacks
Dinner
Food Likes: ___________________________________________________________
Food Dislikes: _________________________________________________________
f. Elimination patterns1. Bowel Movement
Frequency:
Problems or Difficulties:
Usual remedy:
2. Urination
Frequency:
Problems or Difficulties:
Usual remedy:
g. Exercise
h. Personal Hygiene1. Bath
Type:
Frequency:
Time of Day:
2. Oral Care
Frequency:
Care of Dentures:
3. Shaving
Frequency:
4. Use of Cosmetics
i. Recreation
j. Health Supervision
II.C. CLINICAL INSPECTION
Date and Time Taken:
Vital Signs Temperature: Respiratory Rate:Pulse Rate: Blood Pressure:Pain:
Height:
Weight:
II.C.2. Physical Assessment
GENERAL APPEARANCE
A. INTEGUMENTARY SYSTEM
B. NEUROLOGIC SYSTEM
CRANIAL NERVE HOW ELICITED PATIENT’S RESPONSE
CN1 – OLFACTORY
CN2 – OPTIC
CN3 – OCULOMOTOR
CN4 - TROCHLEAR
CN5 – TRIGEMINAL
CN6 – ABDUCENS
CN 7 – FACIAL
CN8 - ACOUSTIC
CN9 – GLOSSOPHARYNGEAL
CN10 – VAGUS
CN11 – SPINAL ACCESSORY
CN12
C. RESPIRATORY SYSTEM
D. CARDIOVASCULAR SYSTEM
E. GASTROINTESTINAL SYSTEM
F. GENITOURINARY SYSTEM
G. REPRODUCTIVE SYSTEM
H. ENDOCRINE SYSTEM
I. MUSCULOSKELETAL SYSTEM
J. LYMPHATIC SYSTEM
K. HEMATOPOETIC SYSTEM
II.B. PSYCHOSOCIAL ASSESSMENT
1. Lifestyle Information:
2. Normal Coping Patterns:
3. Understanding of Current Illness:
4. Personality Style:
5. History of Psychiatric Disorder:
6. Recent Life Changes or Stressors:
7. Major Issues Raised by Current Illness:
II. Mental Status Examination
a. AppearanceNeat Clean Disheveled Poor Grooming Erect Posture
Good Eye Contact Inappropriate Make-up Others: _______________
Description:
b. BehaviorCalm Appropriate Restless Agitated Compulsions
Unusual Actions Others: ____________________
Description:
c. Speech
Appropriate Pressured Loose Association Loud Soft Mute
Others:
Description:
d. Mood/ AffectAppropriate Labile Flat Depressed Worried Anxious
Angry Others_____________
Description:
e. Thoughts
Appropriate Low Self-esteem Suicidal Ideations Hallucinations
Delusions Phobias Others:
Description:
f. Ability to Abstract
Impaired: YES NO
Description:
g. Memory
Impaired recent memory: YES NO
Impaired past memory: YES NO
Number of objects able to remember after 5 minutes: _____
Description:
h. Estimated Intelligence
Below Average Average Above Average
Description:
i. Concentration
Able to focus Easily Distractible
Able to subtract backwards by 7’s from 100 correctly until number
Description:
j. OrientationPerson Time Place _____ Situation ______
k. JudgmentRealistic decision making: YES NO
Description:
l. Insight
Good Fair Poor Description:
Clinical Manifestations
Signs and Symptoms found in textbook Signs and Symptoms manifested by the Client
TEXTBOOK DISCUSSION
