Far Eastern University

Institute of Nursing

INDIVIDUAL/ GROUP NURSING PROCESS FORMAT

I. TITLE PAGE (1 whole page)

A Case of:
(Diagnosis)___________

Presented by:
Name of Student / Group / Section

Presented to/Submitted to:

Name of Faculty__________

Submitted on:
Date Submitted_________

II. DEMOGRAPHIC PROFILE (Page 2)

Demographic Data
Name:
Address:
Age: Birth Date: Birth Place:
Gender:
Religion: Race/Ethnic Origin:
Occupation: Educational Attainment:
Marital Status: Name of Spouse:
Number of Children:
Chief Complaints:
Date of Admission:
Room & Bed Number:
Attending / Admitting Physician:
Admitting/Final Diagnosis:
Medical Insurance:

III. NURSING HEALTH HISTORY

A. History of Present Illness
1. Signs and Symptoms 4. Effect to other body parts/functions
2. Inclusive dates 5. Intervention/treatment done
3. Precipitating and alleviating factors 6. Effect of intervention/treatment

B. Past Health History

1. Immunizations 5. Accidents/Injuries
2. Childhood Illness 6. Hospitalizations
3. Past Illnesses 7. Surgical procedures done
4. Heredofamilial disease 8. Travels local and abroad

C. Obstetric History (For OB Patients ONLY)

D. Pediatric History (For PEDIA Patients ONLY)
(Developmental Milestone)
E. Occupational History (For ADULT patients ONLY)

Inclusive Dates/Years Occupation

 F. Family History (Include genogram with legend)

Grandparents Grandparents

Aunts/Uncles Father Mother Aunts/Uncles

Spouse Patient Siblings

Children

Legend:
- Female ------ - Committed relationship X - Deceased
(Married)
- Male --//-- - Broken relationship (Divorced)

IV. GORDON’S HEALTH ASSESSMENT

1. NARRATIVE form
2. Analysis (with reference) & interpretation after each pattern

A. Health Perception – Health Management Pattern

♦ client’s perceived pattern of health and well-being and how health is managed.

B. Cognitive – Perceptual Pattern

♦ sensory, perceptual, and cognitive pattern according to age level

C. Self-perception – Self-concept Pattern

♦ self-concept and perception of self (body comfort, image, feeling state)

D. Role – Relationship Pattern

♦ pattern of role engagements & relationships according to ordinal position & role in society)

E. Sexuality – Reproductive Pattern

♦ pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive
patterns according to age level

F. Coping – Stress Tolerance Pattern

♦ general coping patterns and effectiveness of the pattern in terms of stress tolerance

G. Value – Belief Pattern

♦ pattern of values and beliefs, including spiritual and moral that guide choices or
decisions according to age level
 H. Nutritional- Metabolic Pattern
• Pattern of food and fluid consumption relative to metabolic need
• 3 day food recall with computations

I. Elimination Pattern
• Pattern of excretory function (bowel, bladder, & sweating/vomiting)

J. Activity – Exercise Pattern

• Pattern of exercise, activity, leisure, and recreation (7 days)
K. Sleep – Rest Pattern
• Patterns of sleep, rest, and relaxation (7days)

V. PHYSICAL ASSESSMENT ( CEPHALO CAUDAL)

a. General Survey
b. Measurements (Height, Weight, BMI, Vital signs)

Assessment Body Part Norms Actual Findings Analysis & Interpretation

Method Used (Cephalo-caudal) (with reference)

VI. Problem Identification and Prioritization

Nursing Diagnosis Rank Justification

Cues according to ABC or Maslows

VII. NURSING CARE PLAN

Cues Nursing Analysis Goal Intervention Rationale Evaluation

Diagnosis
(with references) (Based on
Nsg prob)
Subjective Maybe a. Brief Objective a. Independent (With Narrative
NANDA explanation in (w/ EBN) reference) Based on
Objective narrative form (Based on objective
(at least 4 Etiology)
each) b. Start from b. Dependent Parameters:
diagnosis, to SMART Adequacy
the etiology to Effectiveness
symptoms c.Collaborative Appropriateness
then end point Efficiency
is the nursing Acceptability
problem