Nursing Process

I. Biographic Data

Name:

Address:

Age:

Marital status:

Room and bed:

Chief complaint:

Providional Diagnosis:

Attending Physician:

II. Nursing History

A. Past Health History

1. Childhood Illness

2. Immunizations

3. Allergies

4. Accidents

5. Hospitalization

6. Medications used or currently taken

7. Foreign travel (when, length of stay)

B. History of Present Illness

C. Family History

D. Obstetric History (for OB cases only)

E. Developmental History (for Pediatrics cases only)

III. Patterns of Functioning

A. Psychological Health

1. Coping Patterns

2. Interaction Patterns

3. Cognitive Patterns

4. Self-Concept

5. Emotional Patterns

6. Sexuality

7. Family Coping Patterns

Interpretation:

Analysis:

B. Socio-Cultural Patterns
1. Cultural Patterns
2. Significant Relationships
3. Recreation Patterns
4. Environment
5. Economic

Interpretation:

Analysis:

C. Spiritual Patterns
1. Religious Beliefs and Practices
2. Values and Valuing

Interpretation:

Analysis:

IV. Activities of Daily Living

ADL Before During Interpretation

Hospitalizatio Hospitalizatio and Analysis
n n
1. Nutrition
 2. Elimination
3. Exercise
4. Hygiene
5. Substance
Use
6. Sleep and
Rest
7. Sexual
Activity

V. Physical Assessment

Norms Actual Interpretation

Findings and Analysis
General
Appearance
1. Posture/Gait
2. Skin color
3. Personal
Hygiene/
Grooming
4. Nutritional
Status
5. Age
Appropriateness
6. Verbal Behavior
7. Non-verbal
Behavior
Measurement
1. Temperature
2. Pulse Rate
3. Respiratory
Rate
4. Blood
Pressure
5. Weight
6. Height

Body Part Norms Actual Interpretation

(Technique Findings and Analysis
used)

VI. Laboratory and Diagnostic Examinations Results

Date Procedure Norms Result Interpretation

and Analysis
VII. Medications, IV Infusions, Blood Transfusion, Treatment Given

Gener Dosage/ Classifi Indicati Contraindic Side Nsg.

ic/ Frequen cation on ation Effe Responsibi
Trade cy ct lities
Name

Treatm Classificati Indication Contraindic Nsg.

ent/Inf on ation Responsibilitie
usion s

VIII. Pathophysiology

IX. Ecologic Model

A. Hypothesis

B. Predisposing Factors

1. Host
a. Age
b. Sex
c. Race
d. Nationality
e. Behavior
f. Customs
g. Heredity

2. Agent
a. Mechanical
b. Physical
c. Chemical

3. Environment
a. Physical
b. Biologic
c. Socio-economic

C. Ecologic Model
1. Lever
2. Wheel
3. Web
 4. Triangle

D. Analysis (with reference)

E. Conclusion and Recommendations

X. Prioritized List of Nursing Problems

Date Nursing Cues Justification

Problems
Identified

XI. Nursing Care Plan

Nursi Analysis Goal/Object Nursing Rational Evaluation

ng ives Interventio e
Probl ns
em
Cues
NAND Scientific SMART Supplement (With Effectiveness
A Implication al Referenc Efficiency
Immediate Developmen e) Adequacy
Subj. Cause tal Appropriatene
Intermedia Facilitative ss
Obj. te Cause Acceptability
Root Cause
Discharge Plan
(to be submitted by students whose patients are for discharge)

M – Medications to take at home

E – Exercise
T – Treatments
H – Health Teachings
O – Out patient follow up
D – Diet
S – Sexual Activity (optional)