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COLLEGE OF NURSING
La Paz, Iloilo City NURSING PROCESS INTENSIVE CARE UNIT I. VITAL INFORMATION
Name: Age: Sex: Address: Civil Status: Religious Affiliation: Educational Attainment: Allergies: Date/Time of Hospital Admission: Chief complaint: Ward: Bed/ Cubicle No.: Physicians initials: Impression/Diagnosis: Pre-op Diagnosis: Post-op Diagnosis: Surgical Operation Performed: Number of Days Post-op: II. CLINICAL ASSESSMENT A. NURSING HISTORY 1. History of Present Illness a. Usual Health Status
b. Chronologic Story
d. Disability Assessment
b. Immunizations Type 1st dose BCG DPT OPV MMR Hepa B Others Age 2nd dose Age 3rd dose Age Booster 1 Age Booster 2 Age
c. Allergies NONE d. Accidents and Injuries NONE e. Hospitalization for serious illness NONE f. Medications
3. Family History of Illness NONE 4. Patterns of Functioning a. Breathing Patterns Respiratory Problems: Usual Remedy: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.: c. Sleeping Patterns
Usual bedtime: Waking-up time: Number of pillows: Bedtime rituals: Problems regarding sleep: Usual remedy: d. Drinking Patterns: Type of Fluid Amount
Total amount in 24 hours: e. Eating Patterns Usual Food Taken Breakfast Time
Lunch
Snacks
Supper
f. Elimination Patterns 1. Bowel Movement Bowel Movement: Urination: 2. Urination Frequency: Problems: Usual Remedy: g. Exercise:
h. Personal Hygiene
1. Bath Type: Frequency: Time of Day: 2. Oral Care Frequency: Care of Dentures: 3. Shaving Frequency: 4. Use of Cosmetics: i. Recreation:
j. Health Supervision:
II.B
1. Lifestyle Information
4. Personality Style
C. CLINICAL INSPECTION Date & Time Taken: Vital Signs Temperature: Pulse Rate: Height: Weight: C.1. Primary Survey Airway: Respiratory Rate: Blood Pressure:
Breathing:
Circulation:
Disability:
Integumentary System:
Neurologic System:
HOW ELICITED Ask patient to close eyes. Test each nostril by asking patient to inhale deeply and identify objects being smelled.
NORMAL RESPONSE Identifies an odor on each side of the nose. Smell normally is decreased bilaterally with aging.
PATIENTS RESPONSE
Ask patient to read a certain text at a distance of 14 inches for near vision and at a distance of 20 feet for distant vision. Examine vision acuity using a Snellen Chart
Able to read word/ text at a distance of 14 inches for near vision and at a distance of 20 feet for distant vision. Identifies the characters on the Snellen Chart. Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(vertical direction) Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(diagonal direction) Able to clench jaw. Able to feel cotton wisp stroked on face and respond by saying yes each time she feels the stimulus.
Ask patient to follow directions of the examiners index finger as it moves into the six cardinal fields. Assess pupils response to light.
Ask patient to follow directions of the examiners index finger as it moves into the six cardinal fields. Assess pupils response to light.
Ask patient to clench jaw. Stroke patients face lightly with a cotton wisp and instruct to respond by saying yes each time she feels the stimulus.
Ask patient to follow directions of the examiners index finger as it moves into the six
Able to gaze through all cardinal positions of gaze. Pupils equally round reactive to light and accommodation.(horizontal
cardinal fields. Assess pupils response to light. Cranial Nerve VII (Facial) Observe symmetry of facial expressions. Ask patient to frown, raise eyebrows, wrinkle forehead, close eyes and keep them closed against the examiners resistance, smile, show teeth, purse lips, and puff cheeks against resistance of examiners hand. Test tasting sensation. Instruct patient to identify taste being placed on tongue.
direction)
Facial expressions are symmetrical. Able to frown, raise eyebrows, wrinkle forehead, close eyes and keep them closed against the examiners resistance, smile, show teeth, purse lips, and puff cheeks against resistance of examiners hand.
Perform Voice-Whisper Test. Ask patient to occlude one ear while you whisper a two-syllable word. Ask patient to repeat the word. Test on both ears.
Examine soft palate, uvula Cranial Nerve IX (Glossopharyngeal) movement and gag reflex. Assess patients ability to swallow. Cranial Nerve X (Vagus) Motor: Assess for rise of soft palate and uvula upon phonation. Depress a tongue blade on posterior tongue to elicit gag reflex. Note any hoarseness in voice. Have patient say ah. Observe for symmetric rise of uvula and soft
Soft palate and uvula rises bilaterally and symmetrically upon phonation.
palate.
Instruct patient to turn head sideways against the resistance of examiners hand. Instruct patient to raise shoulders against downward resistance.
Able to turn head sideways and able to raise shoulders against resistance.
C. Respiratory System
D. Cardiovascular System
E. Gastrointestinal System
F. Genito-Urinary System
G. Reproductive System
H. Endocrine System
I. Musculoskeletal System
J. Lymphatic System
K. Hematopoeitic System
C.3. Mental Status Examination APPEARANCE Neat Clean Disheveled Erect Posture Good eye contact Description:
Restless
Agitated
Compulsions
Unusual Actions
Pressured
Loose Association
Loud
Soft
Mute
Flat
Depressed
Worried
Anxious
Angry
Hopeless
Low Self-esteem
Suicidal Ideations
Hallucinations
Delusions
Phobias
MEMORY Impaired recent memory: YES NO Impaired past memory: YES NO No. of objects able to remember after 5 min.: _____ Description:
Above Average
CONCENTRATION Able to focus Easily distractible Able to subtract backwards by 7s from 100 correctly until number _____. Description:
ORIENTATION Person:
YES
NO
Fair
Poor
IV. Date
Done
Invasive/Noninvasive
Rationale
B. Progress Notes
Date
Time Nurses Progress Notes Time Doctors Orders
Date
Time Nurses Progress Notes Time Doctors Orders
Date
Time Nurses Progress Notes Time Doctors Orders