SYSTEM ASSESSMENT Guide

SYSTEM ASSESSMENT
I. ANATOMY AND PHYSIOLOGY

This is the part that discusses all the basic knowledge regarding Anatomy and
Physiology of any specific organ(s) or even the body system(s) primarily involved in
the case. It is most suggested that, the presenter identifies the specific function(s)
that are directly or indirectly involved with the the patient’s case.
II. NURSING HISTORY
A. BIOGRAPHIC DATA
(Included here are data about the patient which may serve best to better
understand the case. These data may or may not only be limited to the data
listed below.)
*Must choose a name that will represent the

Patient’s Name
patient; patient’s real name is kept confidential
*only the City and Province; never indicate the
Address
complete address of patient
Age
Birth date
Birthplace
Sex
Marital Status
Nationality
Occupation
Religion
Usual Source of Medical
Care
*Must choose a name that will represent the
Attending Physician/s physician; physician’s real name is kept
confidential
Primary –
Source/s of Information Secondary –
Tertiary –
B. CHIEF COMPLAINT(S)/ PRIMARY DIAGNOSIS
C. HISTORY OF PRESENT ILLNESS

(This section of the health history takes into account several aspects of the health
problem. First, encourage the patient to explain the health problem or symptom
in as much detail as possible by focusing:
• on the onset, progression, and duration of the problem;

• sign, symptoms and related problems;
• what the patient perceives as causing the problem;
• any precipitating factor(s);
• any alleviating or aggravating factor(s);
• treatments recommended either complied or not and;
• when the symptoms started
• whether the onset of symptom was sudden or gradual
• how often the problem occurs
• character of complaint
• direct activity in which the patient was involved
• how the problem(s) affect(s) the daily life or lifestyle.
D. HISTORY OF PAST ILLNESS

(This section of the health history focuses on questions related to the
patient’s past. The data may point to either the strengths (compliance to check-
ups, medications, or any treatments suggested, etc) or the weaknesses
(smoking habits, alcoholism, sedentary lifestyle, poor or bad diet, and etc.) of the
patient with regards to his/her health concerns or behaviors. The information
gained from these questions assists in identifying risk factors that stem from previous
health problems. Risk factors may be to the patient or to his significant others.
Information covered in this section includes questions about:
• Birth
• Growth
• Development
• Childhood diseases
• Immunizations
• Allergies (Food, Drugs, etc.)
• Previous health problems
• Hospitalizations
• Surgeries
• Pregnancies
• Births
• Previous accidents
• Accidents and Injuries
• medications
• Pain experiences and
• Any emotional or psychiatric problems.
E. HEREDOFAMILIAL DISEASES
DISORDERS MATERNAL PATERNAL

DM (both types)
Hypertension
Asthma
Cancer (Specify the location if positive) (Specify the location if positive)
Food and Drug Allergies (specify the specific food and/or drug) (specify the specific food and/or drug)
F. LIFESTYLE
This is a very important section of the health history because it deals with the
patient’s human responses, which include nutritional habits, activity and exercise
patterns, sleep, and rest patterns, use of medications and substances, self-concept
and self-care activities, social and community activities, relationships, values and
beliefs system, education and work, stress level and coping style, and environment.
The information may or may not only be limited to the following data:
• Description of a typical day (Activities of Daily Living)
• Nutrition/diet
• Activity Level or Exercise
• Sleep and rest
G. SOCIAL DATA
Included in here are all the information about the patient’s social activities that
can help in soliciting information about the patient for support and relaxation and if
the patient is involved in the community beyond family and work. Information in this
section helps to determine the patient’s current level of social development.
• Family relationships/friendships
• Ethnic affiliation (customs & beliefs, cultural practices that may affect
health care and recovery)
• Educational history
• Occupational history (current employment status, days missed from work
because of illness, history of accidents on the job, occupational hazards
with a potential for future disease or accident, patient’s overall satisfaction
with work)
• Economic status
• Home and neighborhood conditions
H. PSYCHOLOGICAL DATA
This is the part that investigates the amount of stress the patient perceives, and
he/she is under and how he/she copes with it. The data may include all the
information about events that cause stress for the patient and how he/she usually
responds. In addition, find out what the patient does to relieve stress and whether
these behaviors or activities are effective or not.
I. PATTERNS OF HEALTH CARE
(This part discusses on all the matters regarding the patient’s behavior towards
medications or treatments)
IV. PHYSICAL ASSESSMENT
A. BASELINE DATA
Height:
Weight:
TPRBP:
Date/Time BP T P R
February 14, 2021
8am 150/100 mmHg 36.3 O C 89 bpm 22 cpm
B. OVERALL APPEARANCE OF THE PATIENT
C. PER SYSTEM ASSESSMENT

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SYSTEM ASSESSMENT

I. ANATOMY AND PHYSIOLOGY

II. NURSING HISTORY

*Must choose a name that will represent the

B. CHIEF COMPLAINT(S)/ PRIMARY DIAGNOSIS

C. HISTORY OF PRESENT ILLNESS

• on the onset, progression, and duration of the problem;

D. HISTORY OF PAST ILLNESS

DISORDERS MATERNAL PATERNAL

IV. PHYSICAL ASSESSMENT

B. OVERALL APPEARANCE OF THE PATIENT

C. PER SYSTEM ASSESSMENT

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