NURSING HEALTH ASSESSMENT I

Student Name: ___Group W__________________ Date/s of Care: _October 25-31, 2020 __ Score: _________
Area of Assignment: NICU__________________ Clinical Instructor: __ _________

DEMOGRAPHIC DATA

Name: ___Patient Z________________________ Age: Newborn __ Sex: __M____ Status: __Newborn___

Address: _____N/I_________________________ Religion: _N/I____ Occupation: _____N/A_______

HEALTH HISTORY
A. Chief Complaint/s:
 For monitoring

B. Impression/Admitting Diagnosis:
 Alive Bb boy, 3.5 kgs, term, 38wks AOG, AS 7,9, Cephalic Delivery via NSD

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated
symptoms, previous treatment and result, social and vocational responsibilities)
On September 7, 2019, 7:30 am, a 19 years-old woman delivered a baby boy at 38 weeks gestation, delivered
with clear amniotic fluid in cephalic presentation via NSD, weight:3.5 kg. No further complications are post-
delivery.

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/ health
maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia)

 N/I

E. Health Habits
Kind Frequency Amount Period
1. Tobacco None None None None
2. Alcohol None None None None
3. OTC drugs None None None None

F. Family History with Genogram

History of Heredo-familial diseases:
____ Cancer
__/_ DM
____ Asthma
__/_ Hypertension
____ Cardiac Disease
____ Mental Disorder
____ Others: _____________

Genogram (up to 3rd generation)

Patient’s Name / Room No. | 1

 Legend:

female
N/I N/I N/I N/I
male

hypertensiv N/I N/I

e

diabetic 19 y.o N/I

patient

miscarriage Newborn

G. Patient’s Perception
Present Illness:
 N/I

Hospital Environment:
 N/I

H. Summary of Interaction:
 Pt is a sleep throughout the assessment process

Patient’s Name / Room No. | 2