Académique Documents
Professionnel Documents
Culture Documents
Source of Information
Reason for Admission
Today’s Chief Concern
(Patient, Parent, Nurse)
Present Diagnosis
Present Surgery
Medical History
Surgical History
_________________________________________________
Religion
Primary Caregiver/s and relationship/s
Communication Difficulties
History of Blood Transfusions
Meds taken at Home
Prescribed Diet
Current Activity Order
Current PT, OT, or ST ordered
ASSESSMENT
Temperature
Radial Pulse
Apical Pulse
Respirations
Blood Pressure
Pulse Oximetry
Height Appropriate for Age?(check developmental graph)
1
ASSESSMENT DESCRIPTION
General Appearance
Mental status Disoriented Oriented Person Place Tim
e
Memory Short Term Long Term
2
ASSESSMENT OF ADL PATTERNS
Mobility Independent Dependent Describe
Hygiene
Toileting
Feeding
Dressing
Other
Unable to Evaluate Above Due to
ASSESSMENT OF INTEGUMENT
Where/description/Etiology?
Scars
Lacerations
Ecchymosis
Diaphoresis
Rashes
Ulcerations
Blisters
Other
IV Site
Loss of Appetite
Nausea
Vomiting
Heartburn
Chewing Problems
Swallowing Problems
Condition of Teeth/Gums/Mucous
Membranes
Skin Turgor
Recent Changes in Weight
Intake and Output(Fluids in and out
your shift)
Unable to Evaluate Above Due To
3
ASSESSMENT OF ELIMINATION PATTERNS
Usual Bowel Pattern(at home)
Laxative or Enema Use
Characteristics of Stool(color,
consistency, quantity)
Last Bowel Movement
Flatus
Bowel Sounds( 4 Quadrants)
Abdomen Soft Distended
Presence of History of Incontinence Pain Burning
(give Dates)
Frequency Retention Difficulty Voiding
Drainage Devices
Unable to Evaluate Above due to:
Breath Sounds
Dyspnea
Cough/Sputum (Frequency/Color,
quantity and tenacity)
Airways Endotracheal Tracheal Ventilator
Presence or History of Bronchitis Pneumonia Orthopnea Asthma
(Give Dates)
Wheezing Respiratory Tx Exposure to Smoking
Noxious (Pks/d/m
Fumes #yrs.
Unable to Evaluate Above Due To:
4
TEXTBOOK PICTURE
Medical
Diagnosis:_______________________________Student____________________________________
Definition:
______________________________________________________________________________________
________________
Etiology:
______________________________________________________________________________________
________________
PATHOPHYSIOLOGY
Describe in as much detail as possible, the pathophysiology (Not signs and Symptoms)
underlying the client’s medical diagnosis and relate it to nursing needs.
Signs/Symptoms:
5
Usual Diagnostic Workup(Tests and exams usually done for this condition):
______________________________________________________________________________________
________________
______________________________________________________________________________________
________________
Pt’s Developmental Stage: (According to Erickson)
(Describe Behavior that correlates with age)
6
LABORATORY RESULTS
Include those pertinent to nursing and medical diagnoses. Include normal values and client results. Include reason(s) for abnormal findings.
NAME OF TEST NORMAL CLIENT’S RATIONALE FOR THIS CLIENT’S NURSING INTERVENTIONS
VALUES RESULTS RESULTS (Pre-test, post-test and resulting from test results)
7
DIAGNOSTIC STUDIES
Include those pertinent to nursing and medical diagnoses. Include normal parameters and client results. Include reason(s) for abnormal findings
NAME OF TEST NORMAL CLIENT VALUES RATIONALE FOR THIS CLIENT’S NURSING INTERVENTIONS(Pre and Post-test and some
VALUES RESULTS resulting from test results)
8
PLAN OF CARE*
Actions(4)
RELATED TO
AS EVIDENCED BY Teaching(2)
9
PATTERN NURSING MUTUALLY NURSING SCIENTIFIC EVALUATION AND
MANIFESTATION DIAGNOSIS DEVELOPED INTERVENTIONS RATIONALES AND MODIFICATION
OUTCOMES REFERENCES
NANDA
STATEMENT(Cont
10
11
12