NURSING ASSESSMENT II

Name of Patient: ________________________________________

Chief Complaints:_______________________________________
Impression/Diagnosis: ____________________________________
Date and time of Admission: ______________________________
Type of Operation (if any):________________________________

Normal Pattern
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

Before Hospitalization
(typical pattern)

Age:______________ Sex: ________________

Inclusive Dates: __________________________
Allergies: ________________________________
Diet: ____________________________________

Initial (loading)
Day 1 (first day of duty)

Clinical Appraisal
Day 2 (second day of duty)

Day 3 (third day of duty)

3. Elimination
a. Urine (frequency, color,
transparency,amount)

b. Bowel (frequency, color,

consistency)

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. Temperature
f. 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)