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NP Vital Info POF

This document contains a nursing assessment form used to collect patient information including vital signs, chief complaint, medical history, family history, patterns of daily living, and expectations of care. The assessment covers areas like past medical history, immunization history, allergies, hospitalizations, medications, breathing, circulation, sleep, nutrition, elimination, hygiene, recreation and health maintenance habits. It aims to gather a comprehensive understanding of the patient's baseline health and needs.

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249 views4 pages

NP Vital Info POF

This document contains a nursing assessment form used to collect patient information including vital signs, chief complaint, medical history, family history, patterns of daily living, and expectations of care. The assessment covers areas like past medical history, immunization history, allergies, hospitalizations, medications, breathing, circulation, sleep, nutrition, elimination, hygiene, recreation and health maintenance habits. It aims to gather a comprehensive understanding of the patient's baseline health and needs.

Uploaded by

ninzestrella
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING PROCESS

I. VITAL INFORMATION
Name: Date of Interview:
Age: Informant:
Sex: Relationship to Patient:
Address:
Civil Status:
Date/Time Admitted:
Chief complaint:

Ward:
Bed No.:
Allergies:
Religious Affiliation:
Physician’s initials:
Impression/Diagnosis:
Pre-op Diagnosis:
Post-op Diagnosis:
Surgical Operation Performed:
Days Post-op:

II. CLINICAL ASSESSMENT

II.A. NURSING HISTORY

1. History of Present Illness


a. Usual Health Status

b. Chronologic Story
c. Relevant Family History

d. Disability Assessment

2. Past Health Problems/Status


a. Childhood Illness

b. Immunizations
Type 1st dose Age 2nd dose Age 3rd dose Age Booster 1 Age Booster 2 Age
BCG
DPT
OPV
MMR
Hepa B
Others

c. Allergies

d. Accidents and Injuries

e. Hospitalization for serious illness

f. Medications

3. Family History of Illness


4. Patient’s Expectations
a. What does he/she expect to occur during this hospitalization?

b. What does he/she expect about nursing care?

5. Patterns of Functioning

a. Breathing Patterns
Respiratory Problems:
Usual Remedy:
Manner of Breathing:

b. Circulation
Usual Blood Pressure:
Any history of chest pain, palpitations, coldness of extremities, etc.:

c. Sleeping Patterns
Usual bedtime:
Waking-up time:
Number of pillows:
Bedtime rituals:
Problems regarding sleep:
Usual remedy:

d. Drinking Patterns:
Type of Fluid Amount

Total amount in 24 Hours:

e. Eating Patterns
Usual Food Taken Time
Breakfast

Lunch
Dinner

Snacks

Food likes:
Food dislikes:

f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems/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:

j. Health Supervision:

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