Republic of the Philippines

Philippine Engineering and Agro-Industrial College, Inc.

College of Nursing
Datu Gonsi St., Lomidong, Marawi City

Name of Student Adam,Fahad M. & Gauraki,Abubakar O. Clinical Instructor Sherlin C. Omungan

Area of Assignment Mulondo Lanao del sur- brgy,Dalama Date Submitted June 7,2024
Date of Exposure: June 3, 2024
NURSING ASSESSMENT I
I. DEMOGRAPHIC DATA
Patient’s Initials: S.B Address [Link] Age 43___________________________________

Sex Female ( / ) Male ( ) Religion Islam Civil Status Married Occupation Housekeeper___________

II. HEALTH HISTORY

A. Chief Complaint/s: Inability to sleep regularly

B. Impression/Admitting Diagnosis:

C. History of Present Illness {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, include obstetrical history, LMP and EDC for OB
patient; affected diagnosis}. The patient has no history of present illnesses.

D. History of Past Illness (previous hospitalization, injuries, procedures, infectious disease, immunization, health maintenance, major illnesses, allergies, medications, habits, birth and developmental history,
nutrition- for pedia) The patient has no history of pass illnesses.
E. Habits
Frequency Amount/Dose Period/Duration
 Smoking Every 10 minutes 1 stick 1 pack for 12 hours
 Drinking None None None____________
 OTC Medications None None None____________

F. Family History with Genogram

Legend: Acquired Diseases:
Hypercholesterolemia X
Female Kidney Disease X
Tuberculosis X
Alcoholism X
Male Drug Addiction X
Hepatitis A X
B X
Patient For Acquired and Heredo-familial
C X
Others (pls. specify) X disease:

Determine which side (or specific member of

Heredo- familial Diseases: the family. Ex. Paternal, Maternal, Sibling, Self
Diabetes X
Heart Diseases X
Hypertension X
Cancer X
Asthma X
Epilepsy X
Mental Illness X
Arthritis X

Others (pls. specify) X

G. Patient Perception of:

Present Illness: The patient has no present of illness as verbalized by the patient.
 Hospital Environment :

H. Summary of Interaction: According to the pt. She don’t have any disease before until present but she cant just have to manage her mental health status, according to her she have problem about
financial, anxiety , insomnia upon assessment , we receive the pt.

REVIEW OF SYSTEM

Patient’s Initials S.B Address [Link] Date & Time of Assessment June 3,2024/10:15 A.M
Sex Female ( / ) Male ( ) Religion Islam Civil Status Married Occupation House keeper
Age 43 Allergies: None Diagnosis: _______________________________________

Vital Signs:

Temperature: 35.7 02sat: 96%

Pulse: 74bpmm Height (cm): ___________
Respiration: 18RR Weight (kg): ___________
Blood Pressure: 120/80mmHg BMI: _________________

SYSTEM INITIAL ASSESSMENT

FINAL ASSSEMENT (Last day) NURSING DIAGNOSIS

( ) Ineffective coping
( ) Knowledge Deficient
( ) Risk for Injury
( ) Acute Pain
( ) Chronic Pain
GENERAL The pt. Appearance is that,she looks tired and stressful
( ) Self-Care Deficit
( ) Powerlessness
( ) Fatigue
( ) Anxiety
( ) Others: Pls Specify
_________________________________
( ) Ineffective Health Maintenance
Head- Normal ( ) Activity Intolerance
( ) Acute Pain
( ) Chronic Pain
( ) Impaired Swallowing
Eyes- Blur vision, both side ( ) Others: Pls Specify
_________________________________

HEENT Ears- Normal

Nose- Normal

Throat- Normal
 ( ) Risk for Ineffective Airway
Clearance
( ) Risk for Deficient Fluid Volume
( ) Risk for Infection
( ) Acute Pain
( ) Impaired Skin/Tissue Integrity
( ) Knowledge, Deficient
INTEGUMENTARY Rashes for both hand was noted ( ) Nutrition: Less than Body
requirement, Imbalanced
( ) Risk for Peripheral Neurovascular
Dysfunction
( ) Impaired Physical Mobility
( ) Others: Pls Specify
_________________________________

( ) Ineffective Airway Clearance

( ) Impaired Gas Exchange
Risk for Infection
( ) Activity Intolerance
( ) Acute Pain
( ) Risk for Deficient Fluid Volume
RESPIRATORY ( ) Deficient Knowledge
Normal ( ) Ineffective Breathing Pattern
( ) Imbalance Nutrition: Less than body
requirement
( ) Impaired Verbal Communication
( ) Others: Pls Specify
_________________________________

CARDIOVASCULAR Normal hearth sound ( ) Decreased cardiac output

( ) Activity Intolerance
( ) Excess Fluid Volume
( ) Impaired Gas Exchange
( ) Ineffective Peripheral Tissue
Perfusion
( ) Impaired Skin/Tissue Integrity
( ) Knowledge Deficit
( ) Risk for Ineffective Breathing
Pattern
( ) Risk for Decreased Cardiac Output
( ) Acute Pain
( ) Others: Pls Specify
____________________________
 ( ) Fluid Volume, deficient
( ) Risk for Shock
( ) Acute Pain
( ) Knowledge, deficient
( ) Diarrhea
( ) Risk for deficient Fluid Volume
( ) Imbalanced Nutrition: Less than
body requirement
( ) Risk for Infection
Normal ( ) Anxiety
( ) Risk for Diarrhea/Constipation
( ) Risk for Impaired Skin Integrity
DIGESTIVE
( ) Disturbed Body Image
( ) Ineffective Coping
( ) Others: Pls Specify
____________________________

( ) Fluid Volume, Excess

( ) Risk for Decreased Cardiac Output
( ) Risk for Deficient Fluid Volume
( ) Risk for Infection
( ) Knowledge, Deficient
( ) Risk for Electrolyte Imbalance
( ) Elimination, Impaired Urinary
( ) Acute Pain
( ) Chronic Pain
( ) Risk for Infection
EXCRETORY ( ) Risk for constipation
Normal
( ) Risk for Bleeding
( ) Self-Care Deficit
( ) Risk for Impaired Skin Integrity
( ) Urinary Incontinence
( ) Others: Pls Specify
____________________________
 ( ) Risk for Injury
( ) Risk for Falls
( ) Activity Intolerance
( ) Risk for Disuse Syndrome
( ) Disturbed Body Image
( ) Others: Pls Specify
____________________________

No presence of abnormalities
MUSCULOSKELETAL

( ) Confusion, Acute
( ) Confusion, Chronic
( ) Altered Sensory Perception
( ) Anxiety
( ) Impaired Memory loss
( ) Disturbed Sensory Perception
( ) Impaired Communication
( ) Impaired Physical Mobility
( ) Ineffective Cerebral Tissue
Perfusion
( ) Impaired Physical Mobility
( ) Others: Pls Specify
NERVOUS Overall normal.
____________________________
 ( ) Knowledge deficient
( ) Disturbed Body Image
( ) Acute Pain
( ) Fatigue
( ) Ineffective Breathing Pattern
( ) Obesity: more than body
requirement, Imbalanced
( ) Nutrition: Less than body
requirement, Imbalanced
( ) Sedentary Lifestyle
( ) Risk for Impaired Skin Integrity
ENDOCRINE ( ) Risk for Deficient Fluid Volume
No presence of masses at the thyroid gland
( ) Risk for Ineffective Tissue Perfusion
( ) Risk for Aspiration
( ) Risk for Infection
( ) Blood Glucose, Unstable
( ) Deficient Fluid Volume
( ) Impaired Liver Function
( ) Nausea
( ) Others: Pls Specify
____________________________

NURSING ASSESSMENT II
Patient’s Initials: S. B. Age: 43_____________________________________
Chief Complaint: Inability to sleep regularly Sex: Female__________________________________
Impression / Diagnosis: ________________________________________ Inclusive Dates of Care: ________________________
Diet: None Allergies: None
Type of Operation to be done/perfomed: ___________________________

Clinical Appraisal
Normal Pattern Before Hospitalization
Initial Day 1 Day 2

1. Activities – Rest -Household chores

-The [Link] short breaks during the day

or delegating tasks to the family.

a. Activities -Slanted
b. Rest
c. Sleeping Pattern

2. Nutritional – Metabolic -Typical food eaten by the poor.

-None

a. Typical Intake -None

(food or fluid)

b. Diet -None
c. Diet restriction
d. Weight -Unknown to the patient
e. Medication/Supplement food
-None
 Clinical Appraisal
Normal Pattern Before Hospitalization
Initial Day 1 Day 2

3. Elimination -Clear,it depends on what she drinks.

-One day,the client had two bowel

a. Urine (frequency, color, movement,the color of the stool was
transparency)
yellow.

b. Bowel (frequency, color,

transparency)

4. Ego Integrity

a. Perception of Self

b. Coping Mechanism
None
c. Support System

d. Mood / Affect

5. Neuro – sensory -Anxiety

- Overall normal
a. Mental State
b. Condition of 5 Senses:
(sight, hearing, smell,
taste, touch)
 Clinical Appraisal
Before Hospitalization
Normal Pattern
Initial Day 1 Day 2

6. Oxygenated and Vital Signs

-18RR
a. Respiratory Rate -74bpm
b. Pulse Rate -35.7*C
c. Temperature -120/80mmHg
d. Blood Pressure -Normal
e. Lung Sounds
-None
f. History of Respiratory Problems

7. Pain Comfort

a. Pain (location, onset, intensity,

duration, associated symptoms,
aggravation)
b. Comfort Measures / Alleviation None
c. Medication

Normal Pattern Clinical Appraisal

Before Hospitalization
 Initial Day 1 Day 2

8. Hygiene & Activities of Daily Living - trice a week in taking a bath

9. Sexually

-Since she was a 13 years old

a. Female (menarche, menstrual cycle,
civil status, number of children, -Every one month
reproductive organ. -Married
-4
-Normal

b. Male (circumcision, civil status,

number of children)

III. LABORATORY AND DIAGNOSTIC PROCEDURES

PATIENT’S INITIALS: _______________________________________________ DATE: ___________________

DATE & NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION NURSING CONSIDERATION
TIME (before and /or after procedure)
 IV. SUMMARY OF MEDICATION
PATIENT’S INITIALS: _________________________________________________ DATE: ___________________

DATE MEDICATIONS DOSAGE ROUTE FREQ REMARKS NURSING RESPONSIBILITIES

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to _________

( ) given ( ) taken ( ) hold, specify reason: ________

( ) d/c, specify date/time: _________ ( ) shifted, specifiy
New route: ________ ( ) changed to __________
 V. SUMMARY OF INTRAVENOUS FLUID
PATIENT’S INITIALS: _________________________________________ DATE: ___________________

DATE/TIME NO. OF INTRAVENOUS FLUID & VOLUME DATE/TIME

DROP RATE NUMBER OF HOURS COMPUTATION
STARTED BOTTLE CONSUMED

VI. INTAKE AND OUTPUT MONITORING SHEET

PATIENT’S INITIALS: _________________________________________ DATE: ___________________
INTAKE OUTPUT

SHIFT TIME IV ORAL NGT TOTAL

TOTAL:
SHIFT URINE NGT/DRAINS PTT/CTT BM OTHERS TOTAL

TOTAL:
 TOTAL INTAKE TOTAL OUTPUT BALANCE

DRUG STUDY

Prescribed,
Generic Name Recommended, Dosage,
Brand Name Frequency, & Route of Mechanism of Action Indications Contraindications Adverse Effect Nursing Responsibilities
Classification Administration

Prescribed:
Generic Name:

Brand Name:

Recommended:

Classification:
 DRUG STUDY

Prescribed,
Generic Name Recommended, Dosage,
Brand Name Frequency, & Route of Mechanism of Action Indications Contraindications Adverse Effect Nursing Responsibilities
Classification Administration

Prescribed:
Generic Name:

Brand Name:

Recommended:

Classification:
 DRUG STUDY

Prescribed,
Generic Name Recommended, Dosage,
Brand Name Frequency, & Route of Mechanism of Action Indications Contraindications Adverse Effect Nursing Responsibilities
Classification Administration
 Prescribed:
Generic Name:

Brand Name:

Recommended:

Classification:

VII. SPECIAL VITAL SIGNS AND NEUROLOGICAL OBSERVATION SHEET

PATIENT’S NAME: _________________________________________________ AGE: __________ SEX: _____________ BED/ROOM NO./ WARD: _____________________

DATE/TIME TEMPERATURE PULSE RATE BLOOD PRESSURE RESPIRATORY OXYGEN PUPIL GCS (E,M,V= REMARKS (LOC; Handgrip; Muscle,
 ARTERIAL SIZES Strength; Limp Movement; Breathing; UO;
RADIAL APICAL CUFF RATE SATURATION TOTAL)
CATHETER (R,L) BM; etc)

VIII. TEMPERATURE, PULSE AND RESPIRATION RECORD

PATIENT’S INITIALS: _________________________________________________ AGE: __________ SEX: _____________ BED/ROOM NO./ WARD: ___________________
 IX. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: INDEPENDENT:

As verbalized by the pt. Inability to sleep At the end of 8 hours of duty ,the The patient will be able to sleep Importance sleeping in health. After 8 hours of duty the
patient will be able to: regularly. patient has able to:

1. Have a progress upon sleeping 1. Developed a progress

2. Have an on time sleeping habit upon sleeping.
2. Improve sleeping habit.

DEPENDENT:

Objective Cues: -The patient appearance is

that,she looks tired and
stressful

COLLABORATIVE:

IX. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: INDEPENDENT:

DEPENDENT:

Objective Cues:

COLLABORATIVE:

IX. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: INDEPENDENT:

DEPENDENT:

Objective Cues:

COLLABORATIVE:

X. ANATOMY AND PHYSIOLOGY

a. Diagram and illustration (drawing of organs(s) / system(s) involved with b. Anatomy & Physiology
appropriate labels of its structure)
 XI. PATHOPHYSIOLOGY

A. Pathophysiology
B. Diagram and Illustration (drawing & diagram/ flow chart of disease process)
 XII. MECHANISM OF LABOR
(for normal OB patients)

A. Mechanism of Labor
b. Diagram and Illustration (Labor and Delivery Process)
 XIII. MEDICAL MANAGEMENT

A. IDEAL B. ACTUAL
 XIV. SURGICAL MANAGEMENT

A. IDEAL B. ACTUAL
 XV. NURSING MANAGEMENT
A. IDEAL B. ACTUAL
 XVI. DISCHARGE PLAN
NAME: _________________________________________________________ AGE/SEX: ____________ ADDRESS:________________________________________________
DATE/TIME OF ADMISSION: _____________________ FINAL DIAGNOSIS: __________________________________________________________________________________________________
DATE/TIME OF DISCHARGE: ____________________ OPERATION/PROCEDURE DONE: ________________________________ ATTENDING PHYSICIAN: _______________________________
CONDITION UPON DISCHARGE: Well and Recovered ( ) With Slightly Improved Condition ( ) Unstable and Needs More Medical Management ( ) Dead ( )
NATURE: May Go Home ( ) Home per Request ( ) Discharged Against Medical Advise ( ) Transferred to Hospital of Choice ( ) Referred to Another Facility ( ) Death ( )
MEDICINE DOSAGE TIME REMARKS/INSTRUCTION

1. MEDICATIONS

2. ENVIRONMENT & EXERCISE /

ACTIVITY LEVEL/ RESTRICTIONS

3. TREATMENTS

4. HEALTH TEACHING
5. OUTPATIENT/ INPATIENT REFERRALS

6. DIETARY INSTRUCTIONS

7. SPIRITUAL

8. SCHEDULE FOR NEXT VISIT

 Republic of the Philippines
Philippine Engineering and Agro-Industrial College, Inc.
College of Nursing
Datu Gonsi St., Lomidong, Marawi City

Patient’s Name: _________________________________________ Age: _________ Sex: __________ Civil Status: _________
Address: ___________________________________ Religion: ___________ Room/Bed No./Ward: _________________________
Date & Time Admitted: ________________________ Admitting Diagnosis: ____________________________________________
Date & Time of Discharge: ____________________________
Chief Complaint: ____________________________________

DATE
DIET LABORATORY TESTS IVF/LEVEL/DUE/TIME

OTHER GADGETS
MEDICATIONS INCLUDING BLOOD (BAG #, TREATMENT ACTIONS
SERIAL #, BLOOD TYPE)

Nurse On Duty Date & Shift Initial Signature Nurse On Duty Date & Shift Initial Signature
 Republic of the Philippines
Philippine Engineering and Agro-Industrial College, Inc.
College of Nursing
Datu Gonsi St., Lomidong, Marawi City

VITAL SIGNS MONITORING SHEET

DATE & TIME ROOM NO/ PR RR 02SAT

NAME OF PATIENT TEMP BP (mmHg) U/O BM NOD
SHIFT BED NO (bpm) (cpm) (%)

Checked by:

_____________________________________________________
Clinical Instructor
NAME: ___________________________________ DATE: ____________________ NAME: ___________________________________ DATE: ____________________

CLINICAL EXPOSURE NARRATIVE REPORT COMMUNITY EXPOSURE NARRATIVE REPORT

 Cut the boxes based on your area of exposure (Paste it on your activity notebook)
 General Objectives
Specific Objectives

TIME & MOTION

TIME MOTION

 Cut the boxes and Paste it on your activity notebook

 Republic of the Philippines
Philippine Engineering and Agro-Industrial College, Inc.
College of Nursing
Datu Gonsi St., Lomidong, Marawi City

NURSE’S PROGRESS NOTES

Name: _______________________________________ Age: __________ Sex: ________ Room/Ward: ___________ Bed No: ___________ Hospital No: ______________________

DATE AND TIME/ SHIFT FOCUS DATA ACTION RESPONSE NOD & SIGNATURE