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: