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West Visayas State University: Nursing Process
West Visayas State University: Nursing Process
West Visayas State University: Nursing Process
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:
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:
Description:
BEHAVIOR
SPEECH
Appropriate Pressured Loose Association Loud
Soft Mute Others: ________________
Description:
MOOD/AFFECT
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
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