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West Visayas State University: Nursing Process

West Visayas State University College of Nursing document outlines the nursing process for assessing a patient in the critical care unit. It includes sections for collecting the patient's biological and health history data, performing a mental status and physical examination, ordering diagnostic tests, documenting significant events, developing a collaborative management plan, writing progress notes, discussing the patient's diagnosis and treatment, and creating a nursing care plan with problems and goals. The document provides a comprehensive guide for nurses to holistically assess, diagnose, plan and evaluate care for critically ill patients.

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365 views4 pages

West Visayas State University: Nursing Process

West Visayas State University College of Nursing document outlines the nursing process for assessing a patient in the critical care unit. It includes sections for collecting the patient's biological and health history data, performing a mental status and physical examination, ordering diagnostic tests, documenting significant events, developing a collaborative management plan, writing progress notes, discussing the patient's diagnosis and treatment, and creating a nursing care plan with problems and goals. The document provides a comprehensive guide for nurses to holistically assess, diagnose, plan and evaluate care for critically ill patients.

Uploaded by

Phylum Chordata
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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West Visayas State University

COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippines
* Trunkline: (063) (033) 320-0870 to 78 loc. 1313 * Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

Vision: WVSU as one of the top universities in Southeast Asia. Mission: To produce globally competitive lifelong learners. Core Values: Service, Harmony & Excellence.

NURSING PROCESS
Critical Care Unit
Date and Time of Interview:
I. Biological Data
Name: Informant:
Address and Contact Person: Relationship to Client:
Age/Birthdate:
Place of Birth:
Gender:
Race/Ethnicity/Nationality:
Religion:
Marital Status:
Educational Level:
Occupation:
Referral:
Advance Directives:
Contact Number:

II. Health Status History


Reason for Admission:
Date and Time of Admission:
Diagnosis Impression:
Pre-Op Diagnosis:
Post-Op Diagnosis:
Surgical Operation Performed:
Number of Days Post Op:
Attending Physician:

Usual Health Status:


Chronologic Story:
Relevant Family History:
Past Health History:
a) Childhood Illnesses
b) Hospitalization & Surgeries
c) Serious Injuries
d) Serious Chronic Illnesses
e) Immunization
f) Allergies (include specific physiological reactions)
g) Medications
h) Recent Travel
i) Family Health History (by Genogram or Listing)
Patient Findings: (e.g. Positive family history for CVD, HTN. MVP, TB and breast
and colon cancer. No family history of stroke, diabetes, obesity, bleeding
disorders, renal disease, seizure or mental disorders.)
West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippines
* Trunkline: (063) (033) 320-0870 to 78 loc. 1313 * Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

Review of Systems:

General Health Survey: Complaints of fatigue. Had two head colds in past year.
No other illnesses. Good exercise tolerance.
Skin, Hair and Nails: No suspicious lesions, no changes in hair or nails.
Head and Neck: Positive headaches, once a month caused by tension. 6/10
pain scale, relieved with Tylenol. Had concussion as a child. No seizures. No neck
pain, masses, has full range of motion (ROM) of neck.
Eyes:
Ears:
Nose and Sinuses:
Mouth and Throat:
Respiratory:
Cardiovascular:
Breasts:
Gastrointestinal:

III. Mental Status Examination


APPEARANCE
Neat Clean Dishevelled Poor grooming Erect
Posture Good eye contact Inappropriate make-up
Others: __________________

Description:
BEHAVIOR

Calm Appropriate Restless Agitated Compulsions


Unusual actions others: _____________________
Description:

SPEECH
Appropriate Pressured Loose Association Loud
Soft Mute Others: ________________
Description:

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried


Anxious Angry Hopeless Others: ______________
Description:
THOUGHTS
Appropriate Low Self-esteem Suicidal Ideations
Hallucinations Delusions Phobias Others: _____________
Description:
West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippines
* Trunkline: (063) (033) 320-0870 to 78 loc. 1313 * Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

ABILITY TO ABSTRACT
Impaired: YES NO

Description:

MEMORY
Impaired recent memory: YES NO
Impaired past memory: YES NO
Number of objects able to remember after 5 minutes: 4/5

Description:

ESTIMATED INTELLIGENCE
Below Average Average Above Average
Description:

CONCENTRATION
Able to focus Easily Distracted
Able to subtract backwards by 7s from 100 correctly until number: __.
ORIENTATION
__Person __Time __Place __Situation

Description:

JUDGMENT
Realistic decision making: YES NO
Description:

INSIGHT
Good Fair Poor

Description:

Adapted from Gorman, L. D. Sultan, & M. L. Raines. (2000). Psychosocial Nursing for
General Patient Care. USA: Lexi Comp Inc.
West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippines
* Trunkline: (063) (033) 320-0870 to 78 loc. 1313 * Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

IV. Physical Assessment


Date and Time Taken:
a.) Primary Survey
Airway:
Breathing:
Circulation:
Disability:
b.) Vital Signs
T: P: R: BP:
Pain:
c.) Secondary Survey (Cephalocaudal Assessment)
A. Height/Weight
B. General Health Survey
C. Integumentary System
D. Respiratory System
E. Cardiovascular System
F. Gastrointestinal System
G. Genitourinary System
H. Reproductive System
I. Musculoskeletal System
J. Neurological System

V. Diagnostic Tests
a. Laboratory Tests
b. Radiologic Tests
c. Other
VI. Summary of Significant Events (since admission)
Date Event
August 3, 2013 Admitted I medical ward
August 4, 2013 Respiratory distress, intubated & ventilated

VII. Collaborative Management


VIII. Progress Notes (day to day account in FDAR format)
IX. Textbook Discussion & Schematic Diagram of the Diagnosis
X. Drug Study
XI. NCP ( 2 Physiologic and Psychological Nursing Problem)

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