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    PA TOOL Virtual Edition

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    Ma. Ydela Meradores
    The document appears to be a nursing assessment form for a patient containing sections for patient profile, family history, review of body systems, drug study, nursing assessment over multiple days, anatomy and physiology, medical and nursing management, and a nursing care plan. The form collects clinical information about a patient to develop an individualized nursing care plan.

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    © All Rights Reserved
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    PA TOOL Virtual Edition

    Uploaded by

    Ma. Ydela Meradores
    25 views16 pages
    The document appears to be a nursing assessment form for a patient containing sections for patient profile, family history, review of body systems, drug study, nursing assessment over multiple days, anatomy and physiology, medical and nursing management, and a nursing care plan. The form collects clinical information about a patient to develop an individualized nursing care plan.

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    PA-TOOL-virtual-edition (2)

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    The document appears to be a nursing assessment form for a patient containing sections for patient profile, family history, review of body systems, drug study, nursing assessment over multiple days, anatomy and physiology, medical and nursing management, and a nursing care plan. The form collects clinical information about a patient to develop an individualized nursing care plan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    25 views16 pages

    PA TOOL Virtual Edition

    Uploaded by

    Ma. Ydela Meradores
    The document appears to be a nursing assessment form for a patient containing sections for patient profile, family history, review of body systems, drug study, nursing assessment over multiple days, anatomy and physiology, medical and nursing management, and a nursing care plan. The form collects clinical information about a patient to develop an individualized nursing care plan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 16

    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

    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)


    REVIEW OF SYSTEMS

    Name Date BMI_______________


    Vital Signs: Height
    Temperature Weight
    Pulse Observation ____________________________________
    Respiration
    Blood Pressure _______

    Sample patient Assigned Case

    1.GENERAL

    2. HEENT

    3. INTEGUMENTARY
    4. RESPIRATORY

    5. CARDIOVASCULAR

    6. DIGESTIVE

    7. EXCRETORY

    8. MUSCULOSKELETAL

    9. NERVOUS

    10. ENDOCRINE

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

    Name Age ____ Sex ____


    Inclusive Dates of Care _ _

    NORMAL PATTERN CLINICAL APPRAISAL

    Day 1 Day 2 DAY 3 DAY 4

    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

    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)

    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

    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)
    ANATOMY AND PHYSIOLOGY

    ]
    MEDICAL MANAGEMENT
    NURSING MANAGEMENT

    SURGICAL MANAGEMENT
    NURSING CARE PLAN
    CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
    NURSING CARE PLAN

    CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


    NAME OF STUDENT: AUBREY DYNISE C. TORRALBA NURSING CARE PLAN CLINICAL INSTRUCTOR: PROF. NORHANIE A. ALI

    CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

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