Nursing Assessment Ii: Normal Pattern Before Hospitalization Clinical Appraisal Initial Day 1 Day 2 Day 3

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NURSING ASSESSMENT II

Name of Patient: ___________________________________ Age: _________ Sex: ______


Chief Complaints: __________________________________ Inclusive Dates: _______________
Impression/Diagnosis: _______________________________ Allergies: ____________________
Date of Admission: _________________________________
Diet: _____________________________________________
Type of Operation (if any):

Normal Pattern Before Clinical Appraisal


Hospitalization
Initial Day 1 Day 2 Day 3
1. Activities – Rest
a. Activities
b. Sleeping pattern
c. Rest

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

1
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 State
b. Condition of 5 senses (sight,
hearing, smell, taste, touch)
6. Oxygenation and Vital Signs
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 measures/alleviation
c. Medication/s
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)
SUMMARY OF MEDICATIONS

DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS

SUMMARY OF INTRAVENOUS FLUIDS

DATE IV FLUID & VOLUME DROP RATE TIME STARTED TIME ENDED INDICATIONS
DIAGNOSTIC AND LABORATORY PROCEDURE/S

PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATIONS NURSING RESPONSIBILITIES


DIAGNOSTIC AND LABORATORY PROCEDURE/S

PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATIONS NURSING RESPONSIBILITIES


DIAGNOSTIC AND LABORATORY PROCEDURE/S

PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATIONS NURSING RESPONSIBILITIES


DIAGNOSTIC AND LABORATORY PROCEDURE/S

PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATIONS NURSING RESPONSIBILITIES


ANATOMY AND PHYSIOLOGY

 
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT

IDEAL ACTUAL
NURSING MANAGEMENT

IDEAL ACTUAL
DRUG STUDY

MEDICATION
DRUG MECHANISM SIDE EFFECTS/ NURSING CONTRAINDICATIONS
(include dosage, INDICATION
CLASSIFICATION OF ACTION ADVERSE REACTIONS RESPONSIBILITIES AND CAUTIONS
route & frequency)
DRUG STUDY

MEDICATION
DRUG MECHANISM SIDE EFFECTS/ NURSING CONTRAINDICATIONS
(include dosage, INDICATION
CLASSIFICATION OF ACTION ADVERSE REACTIONS RESPONSIBILITIES AND CAUTIONS
route & frequency)
DRUG STUDY

MEDICATION
DRUG MECHANISM SIDE EFFECTS/ NURSING CONTRAINDICATIONS
(include dosage, INDICATION
CLASSIFICATION OF ACTION ADVERSE REACTIONS RESPONSIBILITIES AND CAUTIONS
route & frequency)
DRUG STUDY

MEDICATION
DRUG MECHANISM SIDE EFFECTS/ NURSING CONTRAINDICATIONS
(include dosage, INDICATION
CLASSIFICATION OF ACTION ADVERSE REACTIONS RESPONSIBILITIES AND CAUTIONS
route & frequency)
DRUG STUDY

MEDICATION
DRUG MECHANISM SIDE EFFECTS/ NURSING CONTRAINDICATIONS
(include dosage, INDICATION
CLASSIFICATION OF ACTION ADVERSE REACTIONS RESPONSIBILITIES AND CAUTIONS
route & frequency)
NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


NURSING CARE PLAN
Identified Problem:
Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


Subjective: Short Term Objective:

Objective: Long Term Objective:


CLINICAL TEACHING PLAN
Title:
Materials:
General Objectives:

SPECIFIC OBJECTIVES CONTENT TIME ALLOTMENT TEACHING STRATEGY EVALUATION


Cognitive: Introduction:
1.

2.

Psychomotor: Health Teaching Proper:


1.

2.

Affective:
1.

2.

Evalutation:

Closing:
DISCHARGE PLAN

Patient’s Name: ______________________________________________ Date of Discharge: ___________________________


Condition upon 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

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