University of Kirkuk Adult NSG
College of Nursing 2nd years
Nursing Assessment Guide
Student name: Date of Application:
Name of Patient:_________________________________________
Date of Hospitalization:___________________________________
Duration of Hospitalization:________________________________
Name of Hospital:_________________________________________
Patients Demographic Data
Age:____________________ Gender:____________________
Marital Status:__________________ Religion:___________________
Occupation:____________________ Education Level:_____________
Address:__________________________________________________
Medical Data
Diagnosis:_________________________________________
Duration:__________________
Operation Name:____________________________________
Chief Complaints:-
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History of Present illness:
___________________________________________________
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Past Medical History:
Past Surgical History:
Family History:
Drug History:
Etiology of the Disease:-
Serial According to Literature / In Your Patient
Number Books
Clinical Manifestation of the Disease:-
Serial According to Literature / In Your Patient
Number Books
Investigations Conducted for Your Patient:-
Name of Normal Significance of
No. Results
Investigation Range Results
Treatment for Your Patient :-
Name of Side
NO Classification Dose Route Frequency Action
Drug Effects
Vital Signs:
1- Temperature and characters :-
-Sweating
-Cold
-Clammy
-Warm and dry
2-pulse rate and descriptation of rate:
Pulse site: Rate: Rhythm: strength:
Palpitation:
Pulse deficit:
3-Descriptation of heart rhythm:
-Regular: Tachycardia:
-Irregular: Bradycardia:
4-Respiration:
-Rate:
-Depth:
-Character:
-Dyspnea:
5-Blood Pressure:
Systolic:
Diastolic:
- arms: Rt. Arm Lt.
- legs: Rt.Leg Lt.Leg
6-charcteristic of Pain:
-Location: -Radiation: -Duration:
-Intensity:
-Quality:
-Associated factors: -Relieving factors:
7-Presences of :
-Cough: Productive: None Productive:
-Sputum:
-Hemoptysis:
8-Skin color:
-Pallor -Flushing
-Cyanosis -Jaundice
Nursing Care Plan:-
Nursing
Nursing Intervention Rational
Diagnosis
Definition of the Disease:
Alteration/s in the affected system( Pahtophysiology )
References:-
1-
2-
3-
4-
Lecture Evaluation Report
Total Marks Obtained:___________
Signature of Lecture
Date:
Medical Surgical Nursing . Instructor
