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College of Nursing
La Paz, Iloilo City
I. VITAL INFORMATION
Age: Informant:
Address:
Civil Status:
Chief Complaint:
Ward:
Bed No.:
Allergies:
Religious Affiliation:
Physicians Initial:
Impression/Diagnosis:
d. Disability Assessment
b. Immunization
c. Allergies
Medications:
4. Patients Expectations
3
b. What does he/she expect regarding nursing care?
5. Patterns of Functioning
a. Breathing Patterns
Respiratory Problems:
Usual Remedy:
Manner of Breathing:
b. Circulation
c. Sleep Patterns
Usual bedtime:
Number of pillows:
Bedtime Rituals:
Usual Remedy:
d. Drinking Patterns:
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Kinds of fluids taken in 24 Amount in mL or Number in
Hours bottles
Total
e. Eating Patterns
(quantify) (range)
Breakfast
Lunch
Dinner
Snacks
5
Food likes:
Food dislikes:
f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems or Difficulties:
Usual Remedy:
2. Urination
Frequency:
Problems:
Usual Remedy:
g. Exercise:
h. Personal Hygiene
1. Bath
Type:
Frequency:
Time of Day:
2. Oral Care
Frequency:
Care of Dentures:
3. Shaving
Frequency:
4. Use of Cosmetics:
i. Recreation:
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j. Health Supervision:
T= PR =
BP = RR =
II.B.2. Height:
II.B.3. Weight:
General Appearance:
A. INTEGUMENTARY SYSTEM
7
B. NEURO-SENSORY SYSTEM
C. RESPIRATORY SYSTEM
8
D. CARDIOVASCULAR/CIRCULATORY SYSTEM
E. GASTROINTESTINAL/HEPATOBILIARY SYSTEM
F. GENITO-URINARY SYSTEM
G. REPRODUCTIVE SYSTEM
9
H. ENDOCRINE SYSTEM
I. MUSCULOSKELETAL SYSTEM
J. LYMPHATIC SYSTEM
K. HEMATOPOEITIC SYSTEM
10
II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT
1. Lifestyle information
4. Personality Style:
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8. Mental Status Examination
APPEARANCE
Description:
BEHAVIOR
Description:
SPEECH
Description:
MOOD/AFFECT
Description:
THOUGHTS
Description:
ABILITY TO ABSTRACT
12
Impaired: YES NO
Description:
MEMORY
Description:
ESTIMATED INTELLIGENCE
CONCENTRATION
ORIENTATION
JUDGMENT
Description:
INSIGHT
Description:
13
II.D. OTHER SOURCES OF DATA
14
IV. TEXTBOOK DISCUSSION
15
V. PROBLEM LIST
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