Nursing Assessment Ii

NURSING ASSESSMENT II Name of Patient: ___________________________________ Chief Complaints: __________________________________ Impression/Diagnosis: _______________________________ Date of Admission: _________________________________ Diet: _____________________________________________ Type of Operation (if any):

Normal Pattern

Age: _________ Sex: ______ Inclusive Dates: _______________ Allergies: ____________________

Before Hospitalization Initial

1. Activities – Rest a. Activities b. Sleeping pattern c.

Rest

2. Nutrition – Metabolic a. Typical intake (food or fluid) b. Diet c.

Diet restriction

d. Weight e. Medication/Supplement food

Clinical Appraisal Day 1 Day 2

Day 3

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

4. Ego Integrity a. Perception of Self b. Coping Mechanism c.

Support Mechanism

d. Mood/Affect

5. Neuro-Sensory a. Mental State b. Condition of 5 senses (sight, hearing, smell, taste, touch)

6. Oxygenation and Vital Signs a. Respiratory rate b. Pulse rate c.

Heart Rate

d. Blood pressure e. Lung sounds f.

History of respiratory problems

7. Pain – Comfort a. Pain (location, onset, intensity, duration, associated symptoms, aggravation) b. Comfort measures/alleviation c.

Medication/s

8. Hygiene and activities of daily living

9. Sexuality a. female (menarche, menstrual cycle, civil status, number of children, reproductive status) b. Male (circumcision, civil status, number of children)