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    NEW PA Tool Original

    Uploaded by

    Sahara Sahjz Macabangun
    This document contains forms and templates for nursing students to complete assessments, care plans, and documentation for patients. It includes sections for collecting demographic data, health history, physical examination, review of body systems, nursing assessment, diagnostic tests and labs, anatomy and physiology, pathophysiology, drug studies, medication administration records, intravenous fluids, nursing care plans, discharge planning, medical/surgical management, and nursing management. The forms require information about the patient's chief complaints, diagnoses, vital signs, medical history, physical exam findings, lab and test results, medications, treatments, and nursing interventions.

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    Download as DOC, PDF, TXT or read online from Scribd

    NEW PA Tool Original

    Uploaded by

    Sahara Sahjz Macabangun
    675 views15 pages
    This document contains forms and templates for nursing students to complete assessments, care plans, and documentation for patients. It includes sections for collecting demographic data, health history, physical examination, review of body systems, nursing assessment, diagnostic tests and labs, anatomy and physiology, pathophysiology, drug studies, medication administration records, intravenous fluids, nursing care plans, discharge planning, medical/surgical management, and nursing management. The forms require information about the patient's chief complaints, diagnoses, vital signs, medical history, physical exam findings, lab and test results, medications, treatments, and nursing interventions.

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    This document contains forms and templates for nursing students to complete assessments, care plans, and documentation for patients. It includes sections for collecting demographic data, health history, physical examination, review of body systems, nursing assessment, diagnostic tests and labs, anatomy and physiology, pathophysiology, drug studies, medication administration records, intravenous fluids, nursing care plans, discharge planning, medical/surgical management, and nursing management. The forms require information about the patient's chief complaints, diagnoses, vital signs, medical history, physical exam findings, lab and test results, medications, treatments, and nursing interventions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    675 views15 pages

    NEW PA Tool Original

    Uploaded by

    Sahara Sahjz Macabangun
    This document contains forms and templates for nursing students to complete assessments, care plans, and documentation for patients. It includes sections for collecting demographic data, health history, physical examination, review of body systems, nursing assessment, diagnostic tests and labs, anatomy and physiology, pathophysiology, drug studies, medication administration records, intravenous fluids, nursing care plans, discharge planning, medical/surgical management, and nursing management. The forms require information about the patient's chief complaints, diagnoses, vital signs, medical history, physical exam findings, lab and test results, medications, treatments, and nursing interventions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    MINDANAO STATE UNIVERSITY Iligan Institute of Technology College of Nursing NURSING HEALTH ASSESSMENT I

    Student Name: ________________________ Date of Care: __________ Score: ____________ Area of Assignment: _____________________ Clinical Instructor: _______________________ DEMOGRAPHIC DATA Name: __________________________ Age: ________ Sex: ________ Status: _____________ Address: ________________________ Religion: ___________ Occupation: ________________ HEALTH HISTORY A. Chief complaint/s:

    B. Impression/Admitting Diagnosis:

    C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation


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

    D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious


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

    E. Heath Habits Kind 1. Tobacco 2. Alcohol 3. OTC drugs F. Family History with Genogram History of Heredo-familial diseases: ____ Cancer ____ Diabetes ____ Asthma Legend: ____ Hypertension ____ Cardiac Disease ____ Mental disorder ____ Others: ______________ G. Patients Perception Present Illness: Frequency Amount Period

    Genogram (up to 3rd generation)

    Hospital Environment:

    H. Summary of Interaction

    PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS


    NAME: _______________________________________ Vital Signs: Temperature: _______________ Pulse: _______________ Respirations: _______________ DATE: __________________________ Height: _______________ Weight: _______________ Blood Pressure: _______________

    1. General 2. HEENT

    3. Integumentary System 4. Respiratory System 5. Cardiovascular System 6. Digestive System 7. Excretory System 8. Musculoskeletal System 9. Nervous System 10. Endocrine System

    11. Reproductive System

    NURSING ASSESSMENT II
    Name of Patient: _______________________________ Chief Complaints: ______________________________ Impression/Diagnosis: __________________________ Date of Admission: _____________________________ Type of Operation (if any): ___________________________________________ Age: ______________ Sex: ________________ Inclusive Dates: __________________________ Allergies: _______________________________ Diet: ___________________________________

    Normal Pattern 1. Nutrition Metabolic a. Typical intake (food or fluid) b. Diet c. Diet restriction d. Weight e. Medication / Supplement food

    Before Hospitalization

    Initial

    Clinical Appraisal Day 1 Day 2

    2. Elimination a. Urine (frequency, color, transparency) b. Bowel (frequency, color)

    3. Ego Integrity a. Perception of self b. Coping Mechanism c. Support Mechanism d. Mood / Affect

    4. Neuro Sensory

    a. Mental state b. Condition of 5

    SUMMARY OF MEDICATION DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS

    SUMMARY OF INTRAVENOUS FLUID DATE IV FLUID & VOLUME DROP RATE TIME STARTED TIME ENDED INDICATION

    DIAGNOSTIC AND LABORATORY PROCEDURE/S PROCEDURE INDICATION NORMAL VALUE RESULT IMPLICATION NURSING RESPONSIBILITIES

    ANATOMY AND PHYSIOLOGY

    PATHOPHYSIOLOGY

    DRUG STUDY
    MEDICATION (include dosage, route & frequency) DRUG CLASSIFICATION INDICATION MECHANISM OF ACTION SIDE EFFECTS/ADVER SE REACTIONS NURSING RESPONSIBILITIE S CONTRAINDICATI ONS AND CAUTIONS

    10

    NURSING CARE PLAN


    Identified Problem: Nursing Diagnosis: CUES Objective cues:

    OBJECTIVES Short term objective:

    INTERVENTIONS

    RATIONALE

    EVALUATION

    Subjective cues:

    Long term objective:

    11

    DISCHARGE PLAN
    DRUG DOSAGE FREQUENCY ROUTE INDICATION

    Medication

    Exercise

    Therapy

    Health Teachings

    OPD Visit

    Diet

    Spiritual

    12

    MEDICAL/SURGICAL MANAGEMENT (IDEAL AND ACTUAL) IDEAL ACTUAL

    13

    NURSING MANAGEMENT (IDEAL AND ACTUAL) IDEAL ACTUAL

    14

    15

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