Académique Documents
Professionnel Documents
Culture Documents
Gender: Male
1.
History of Present Illness: 1-2 days PTA ---(+)LBM watery, yellowish(4x) foul smelling non bloody
(+) on and off fever
Fever virus PTA= (+) upward rolling of eyeballs, (+) stiffening of extremities,(-) DOB
(-) active bleeding, (+) GI abdominal pain, colicky bleeding, tenderness,(+) cough x few days
(+) loss of appetite
Hospital
Diagnosis
Pagamutang
Mild
bayan ng
dehydration,severe
Carmona
malnutrition and
Treatment
rendered
Medication
pulmonary
tuberculosis 3
ACTIVITY
Frequency and regularity of exercises: ____________________________________
REST
Usual no. of hours of sleep and rest at night: ____________at day time: ________
No. of hours of sleep and rest to feel rested: _______________________________
Change in sleep / rest pattern: __________________________________________
Discomfort or difficulty going to sleep: _____________________________________
Remedy done with the discomfort: _______________________________________
No. of pillows use when sleeping: ________________________________________
c.
Food restrictions:______________________
ELIMINATION PATTERN
i.
Bladder
Frequency and amount of urination per day: _________________________
Color and odor of urine:__________________________________________
Any discomfort in urination:_______________________________________
Remedy and intervention done: ___________________________________
ii.
Bowel
Frequency of bowel elimination per day: ____________________________
Consistency and color of stools:___________________________________
Changes in bowel elimination:____________________________________
Discomfort in Bowel elimination:___________________________________
Intervention done: _____________________________________________
e.
g. SENSES
Any disturbance / difficulty in:
Sight: ________________________
Hearing: ______________________
Touch: _______________________
Taste: _______________________
Smell: _______________________
How long do you have the difficulty?____________________________
How do you manage it?______________________________________
How has this affected your lifestyle:____________________________
Device used?______________________________________________
h.
SKIN INTEGRITY
Pigmentation: ___________________________________________________
Temperature:___________________
Smooth ( )
Rough ( )
Soft ( )
Dry ( )
ENDOCRINE FUNCTION
Age of menarche: _____________
NEUROLOGICAL FUNCTION
Level of consciousness;_________________________________________________
Orientation:_____________ gait:__________________ Posture:______________
Changes in facial, mouth and neck function:_________________________________
Deep tendon reflex:____________________________________________________
Sense of pain and light touch : ___________________________________________
PHYSICAL SELF
Present weight: ___________ Lowest weight: ______________
How do you feel yourself and appearance:_______________________________________
Any physical changes in your body:____________________________________________
Has this changes affected your relationship with others?_____________________________
c.
PERSONAL VALUES
What do you consider as the most valuable / important in your life:____________________
_________________________________________________________________________
With what and who do you find a source of strength or meaning? ____________________
________________________________________________________________________
D.
PSYCHOSEXUAL
(Freud)
PSYCHOLOGICAL DEVELOPMENT
PSYCHOSOCIAL
(Erickson)
Latency
Industry vs
stage
inferiority
E.
(Piaget)
concrete
INTERPERSONAL
MORAL
(Sullivan)
(Kohlberg)
(Fowlers)
Preconventiona
Mythical and
l Morality
literal faith
Vital signs :
a.
Temperature: 39*C
b.
Pulse Rate:
c.
Respiratory Rate: 22
2.
Blood pressure:
3.
Regional Examination:
58 bpm
Results
a. Hair
b. Head
c. Face
d. Eyes
e. Nose
f. Mouth and pharynx
g. Neck
h. Chest wall ( Anterior)
i. Chest wall (Posterior)
j. Breast and Axilla
k. Heart
SPIRITUAL
complementarity
PHYSICAL EXAMINATION
COGNITIVE
Sunken eyeballs
l. Abdomen
m. Skin and nails
n. Anus and Rectum
o. Extremities (lower) *include
ROM and muscle strength
p. Extremities (upper) *include
ROM and muscle strength
q. Urinary
r. Genitals
s. Musculoskeletal
t. Hematology
u. Gastrointestinal
v. Cranial Nerves (I-XII)
If applicable please include Neuromuscular Vital signs / assessment
F. LABORATORY EXAMINATIONS
Purpose of the
Date and
examination to
Type of
Examination
the patients
Nursing
Normal Values
Results of the
examination
Interpretation
case
responsibilities
(before,
during , after)
G. DIAGNOSTIC EXAMINATIONS
Purpose of the
Date and
examination to
Type of
Examination
the patients
Nursing
Normal Values
Results of the
examination
Interpretation
case
responsibilities
(before,
during , after)
I.
Doctors order
order
Include picture of system and brief explanation that relates to the patients.
J.
PATHOPHYSIOLOGY
A. Diagram
Include precipitating and predisposing factors.
B. Tabular
Definition of the diseases
Evaluation or comparison
K. DRUG STUDY
Name of Drug, Classification,
Route, Frequency and
Drug Indication
Nursing Responsibility
Drug Action
Dosage
L.
Cues
(subjective/objective)
Nursing Diagnosis
Objectives
Nursing Intervention
and Rationale
Evaluation
M. PROGRESS NOTES
Day
1.
2.
3.
4.
Key Area
Nutrition
Medication
Activity
Self Care / knowledge on
Plan of Care
treatments
5. Follow up check ups
O. HEALTH TEACHING PLAN
Topic
P.
Objective
Methods of Teaching
Visual aids
Evaluation
Date:
Condition of the patient on his/her last day.