Nephrology Nursing Care

Advanced Health Assessment Form

Hospital/Institution: ……………………………………………………...

Participants/Students Name: ……………………………………………..

Date: ……………………....

Clients Name: ………………………………………. Age: ………... Sex: ………..

Religion: …………………….. Occupation: ………..………... Race: ……………..

Address: ……………………………………………………………………………..

Ward: …………………... Bed No.: ………………. Reg. ………….. No.: ……….

Marital Status:…………………………….. Educational Level: …………………...

Admission Date: ………………………….. Medical Diagnosis: …………………..

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 Date Collection
1. Health history
1.1. Chief complains
………………………………………………………………………………
………………………………………………………………………………
1.2. Present illness
………………………………………………………………………………
2. Functional Heath Pattern Assessment
2.1. Health perception health management pattern …………………………….
…………………………………………..………………………………….
2.2. Nutritional metabolic pattern …………………………………………….…
………………………………………………………………………………
2.3. Elimination pattern …………………………………………………………
……..…………………………………………………………………………
2.4. Activity exercise pattern ……………………………………………………
……………………………………………………………………………. …
2.5. Sleep rest pattern ……………………………………………………………
………………………………………………………………………………
2.6. Cognitive perception pattern ………………………………………….……
……………………………………………………………………………....
2.7. Self-perception and self-concept pattern ……………………………………
………………………………………………………………………………
2.8. Role-relationship pattern ……………………………………………………
………………………………………………………………………………
2.9. Sexuality reproductive pattern ………………………………………………
………………………………………………………………………………
2.10. Coping stress tolerance patter ………………….…………………………
………………………………………………………………………………
2.11. Value believe pattern …………….………………….……………………
…………………………………………………………………….…………
3. Sign and symptoms during taking care of the patient …………….…………….
……………………………………………………………………………………
4. Treatment during taking care of the patient ……………………….…………….
……………………………………………………………………………………

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5. Laboratory and Investigation Date Type of Investigation

Date Types of Investigation Result Normal

Value

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