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Far Eastern University
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MERGEFORMATINET
INDIVIDUAL/ GROUP NURSING PROCESS FORMAT
I. TITLE PAGE (1 whole page)
A Case of:
(Diagnosis)___________
Presented by:
Name of Student / Group / Section
Presented to/Submitted to:
Name of Faculty__________
Submitted on:
Date Submitted_________
II. DEMOGRAPHIC PROFILE (Page 2)
Demographic Data
Name:
Address:
Age: Birth Date: Birth Place:
Gender:
Religion: Race/Ethnic Origin:
Occupation: Educational Attainment:
Marital Status: Name of Spouse:
Number of Children:
Chief Complaints:
Date of Admission:
Room & Bed Number:
Attending / Admitting Physician:
Admitting/Final Diagnosis:
Medical Insurance:
III. NURSING HEALTH HISTORY
A. History of Present Illness
1. Signs and Symptoms 4. Effect to other body parts/functions
2. Inclusive dates 5. Intervention/treatment done
3. Precipitating and alleviating factors 6. Effect of intervention/treatment
B. Past Health History
1. Immunizations 5. Accidents/Injuries
2. Childhood Illness 6. Hospitalizations
3. Past Illnesses 7. Surgical procedures done
4. Heredofamilial disease 8. Travels local and abroad
C. Family History (Include genogram with legend)
Grandparents Grandparents
Aunts/Uncles Father Mother Aunts/Uncles
Spouse Patient Siblings
Children
Legend:
- Female ------ - Committed relationship X - Deceased
(Married)
- Male --//-- - Broken relationship (Divorced)
IV. GORDON’S HEALTH ASSESSMENT
1. NARRATIVE form / During Assessment
2. Analysis (with reference) & interpretation after each pattern
A. Health Perception – Health Management Pattern
♦ client’s perceived pattern of health and well-being and how health is managed.
B. Cognitive – Perceptual Pattern
♦ sensory, perceptual, and cognitive pattern according to age level
C. Self-perception – Self-concept Pattern
♦ self-concept and perception of self (body comfort, image, feeling state)
D. Role – Relationship Pattern
♦ pattern of role engagements & relationships according to ordinal position & role in society)
E. Sexuality – Reproductive Pattern
♦ pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive
patterns according to age level
F. Coping – Stress Tolerance Pattern
♦ general coping patterns and effectiveness of the pattern in terms of stress tolerance
G. Value – Belief Pattern
♦ pattern of values and beliefs, including spiritual and moral that guide choices or
decisions according to age level
H. Nutritional- Metabolic Pattern
Pattern of food and fluid consumption relative to metabolic need
3 day food recall
I. Elimination Pattern
Pattern of excretory function (bowel, bladder, & sweating/vomiting)
J. Activity – Exercise Pattern
Pattern of exercise, activity, leisure, and recreation (7 days)
K. Sleep – Rest Pattern
Patterns of sleep, rest, and relaxation (7days)
V. PHYSICAL ASSESSMENT ( CEPHALO CAUDAL)
a. General Survey
b. Measurements (Height, Weight, BMI, Vital signs)
Assessment Body Part Norms Actual Findings Analysis & Interpretation
Method Used (Cephalo-caudal) (with reference)
VI. Problem Identification and Prioritization
Nursing Diagnosis Rank Justification
Cues according to Maslows
VII. NURSING CARE PLAN
Cues Nursing Analysis Goal Intervention Rationale Evaluation
Diagnosis
(with references) (Based on
Nsg prob)
Subjective a. Brief Objective a. Independent (With Narrative
NANDA explanation in (Supplemental) reference) Based on
Objective narrative form (Based on objective
(at least 3 Etiology)
each) b. Start from b. Interpedendent Parameters:
diagnosis, to SMART (Facilitative) Adequacy
Measurement the etiology to Effectiveness
symptoms Appropriateness
then end point c. Developmental Efficiency
is the nursing Acceptability
problem
