Nursing Assessment Ii: Normal Pattern Before Hospitalization Clinical Appraisal Initial Day 1 Day 2 Day 3
Nursing Assessment Ii: Normal Pattern Before Hospitalization Clinical Appraisal Initial Day 1 Day 2 Day 3
Nursing Assessment Ii: Normal Pattern Before Hospitalization Clinical Appraisal Initial Day 1 Day 2 Day 3
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 IV FLUID & VOLUME DROP RATE TIME STARTED TIME ENDED INDICATIONS
DIAGNOSTIC AND LABORATORY PROCEDURE/S
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:
2.
2.
Affective:
1.
2.
Evalutation:
Closing:
DISCHARGE PLAN
1. Medication
2. Exercise
3. Diet
4. Health Teaching
6. Spiritual
7. Lifestyle
8. Referral