Mindanao State University

Iligan Institute of Technology

DEPARTMENT OF NURSING

ASSESSMENT FORM

Student: ________________________ Score: ____________

Area of Assignment: ______________
Date Submitted: __________________ Clinical Instructor: _________________

PATIENT PROFILE

Name: ________________________ Age:_____ Sex: _______ Status:_____________

Address: _________________________________________________ Religion: ___________

NURSING ASSESSMENT I
A. Chief complaints:

B. History of Present Illness (HPI) (location, onset, character, intensity, duration,

aggravation and alleviation, associated symptoms, previous treatment and result,
social and vocational responsibilities).

C. History of Past illness (previous hospitalization, injuries, procedures, infectious

disease, immunization/health maintenance, major illness, allergies, medication,
habits, birth and development history, nutrition – for pedia).

D. Heath Habits
Frequency Amount Period
1. Tobacco
2. Alcohol
3. OTC drugs/non-prescription drugs

E. Family History with Genogram

Legend: History of Heredo-familial diseases:
Cancer _______
Diabetes _______
Asthma _______
Hypertension _______
Cardiac Disease _______
Mental disorder _______
Others _______

F. Patient’s Perception of
Present Illness:

Hospital Environment:

G. Summary of Interaction

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 REVIEW OF SYSTEM

Name: _________________________________ Date: _____________________

Vital Signs
Temperature: __________
Pulse: __________ Height: __________
Respiration: __________ Weight:__________
Blood Pressure:__________ Observation: _________________________________________

1. General

2. HEENT

3. Integumentary

4. Respiratory

5. Cardiovascular

6. Digestive

7. Excretory

8. Musculoskeletal

9. Nervous

10. Endocrine

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 NURSING ASSESSMENT II

Name of Patient: ______________________________ Age: __________ Sex: __________

Chief Complaints: _____________________________ Inclusive Dates of Care: ________________
Impression/Diagnosis: __________________________ Allergies: ____________________________
Date of Admission: _____________________________
Diet: ________________
Type of Operation (if any):

Clinical Appraisal
Normal Pattern Before Hospitalization
Initial Day 1 Day 2
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

Clinical Appraisal
Normal Pattern Before Hospitalization

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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 sate
b. Condition of 5 sense:
(sight, hearing, smell,
taste, touch)

Clinical Appraisal
Normal Pattern Before Hospitalization
Initial Day 1 Day 2
6. Oxygenation and Vital signs

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 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 measure /
alleviation
c. Medication

Clinical Appraisal
Normal Pattern Before Hospitalization
Initial Day 1 Day 2
8. Hygiene and activities of daily
living

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9. Sexuality
a. Female (menarche,
menstrual cycle, civil
status, number of children,
reproductive status)
b. Male (circumcision, civil
status, number of children)

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 SUMMARY OF MEDICATION

Date Medication Remarks

SUMMARY OF INTRAVENOUS FLUID

Intravenous Fluids
Date/Time Started Drop Rate No. of Hours Date/Time Consumed
& Volume

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 LABORATORY AND DIAGNOSTIC PROCEDURE

NAME OF PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

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ANATOMY AND PHYSIOLOGY

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PATHOPHYSIOLOGY

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 DRUG STUDY

Prescribed and
Recommended
Generic Name
Dosage, Mechanism of Nursing
Brand Name Indication Contraindication Adverse Reaction
Frequency, and Action Responsiblities
Classifications
route of
Administration

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 NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

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 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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