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Nursing Assessment II
Nursing Assessment II
Normal Pattern
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
Before Hospitalization
(typical pattern)
Initial (loading)
Day 1 (first day of duty)
Clinical Appraisal
Day 2 (second day of duty)
3. Elimination
a. Urine (frequency, color,
transparency,amount)
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. Temperature
f. 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)