Far Eastern University

IHSN

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. 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 ( Before and During Hospitalization )
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
 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. LABORATORY/DIAGNOSTIC EXAMINATIONS

Date Done Laboratory/Diagnostic Normal Values Actual Results Clinical Interpretation

Examination Interpretation & Analysis
(with reference)

VII. DRUG STUDY

Mechanism of
Contraindi- Side Adverse Nursing
Name of Drug Action Indication
cation Effects Effects Responsibilities
Generic Name Classification

Brand Name Peak Effect

Route & Dosage

VIII. Problem Identification and Prioritization

Nursing Diagnosis Rank Justification

Cues according to ABC or Maslows

IX. NURSING CARE PLAN

Cues Nursing Analysis Goal Intervention Rationale Evaluation

Diagnosis
(with references) (Based on
Nsg prob)
Subjective a. Brief Objective a. Independent (With Narrative
NANDA explanation in (w/ EBN) reference) Based on
Objective narrative form (Based on (Supplemental) objective
(at least 4 Etiology)
each) b. Start from b. Interdependent Parameters:
diagnosis, to SMART (Facilitative) Adequacy
the etiology to Effectiveness
symptoms c. Developmental Appropriateness
then end point Efficiency
is the nursing Acceptability
problem
X. DISCHARGE PLAN (applicable ONLY if client is for DISCHARGE)
M – Medications to continue at home
E - Exercises
T - Treatments
H – Health Teachings
O – Out Patient (Date/Time/Place/Physician)
D - Diet
S – Sexuality/Spirituality

THE EBN

A. EBN FORMAT
1. General Question
2. Reconstruction of General Question related to client’s problem identified in the RLE.

PICO

Patient Intervention Comparison Outcome

Focus population

3. Critical Review with Summary of the Literature (Attach Literature to output)

 Far Eastern University
Institute of Nursing

EVIDENCE BASED NURSING

Research journals should be up-to-date (year 2019 and up) from research databases (e.g. EBSCO) or from
original sources. Writing style and citation of sources should follow the APA format.

A. Anatomy of a good clinical question consists of:

1. How would you describe a group of patient similar to your client?
2. What are the most important characteristics of the patient? (This may include the primary problem,
disease or co-existing conditions)
3. Sometimes the gender, age, or race of a patient may be relevant to the diagnosis or treatment of a
disease.
B. Intervention, Prognostic Factor or Exposure
` 1. What main intervention, prognostic factor or exposure are you considering?
2. What do you want to do with a client? Why? And How?
a. Prevent a complication
b. Promote a healthy lifestyle
c. Resolve nursing problems
d. Facilitate nursing interventions
C. What factor may influence the prognosis of the client?
1. Age 3. Co-existing problems
2. Economic status 4. Familial factor
D. What was the client exposed to?
1. Cigarette smoke
2. Pollen
3. Asbestos
4. Pollutants
5. Others
E. Comparison
1. What is the main alternative to compare with the intervention?
2. Are you trying to decide between two interventions?
F. Outcome
1. What do you hope to accomplish, measure or effect
2. What are you trying to do for the patient
a. Relieve or eliminate the symptoms/discomfort
b. Reduce the number of adverse events
c. Improve functions

Note: The clinical question does not always need a specific comparison.

Patient/Problem Low back pain

Intervention Acupuncture
Comparison, if any Application of hot and cold compress
Outcome/s Relieves back pain
Promotes relaxation

G. From the given example, a clinical question can be devised:

Example: “Low Back Pain: Is acupuncture more effective than the application of hot and cold
compress in relieving back pain and promoting relaxation?”

H. Related Literature from research databases (e.g. EBSCO) and other sources.