Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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PATIENT STICKER
Received Patient Date /Time: _____________ Marital/ Status: Single / Married___________ Occupation: __________________________ Next of Kin: __________________________ Tel Num: __________________________ Accompanied By: ________________________
Reason of Admission Surgical / Medical History Family History Current Medication Allergies (Drugs / Food / Environment)
Daily Activities of Living: BODY HYGIENE Assist Dependent DIET Normal Vegetarian
Normal
Abnormal SKIN Colour (Pale, Cyanosed) Temp (Warm, Cold. Moist) Rashes Oedema Urticaria Jaundice Eczema Bedsore Nails (Pale, Cyanosed) www.niche.edu.my
MICTURATION incontinence nocturia dysuria polyuria catheter NUTRITION/APPETITE poor nausea vomiting assist SMOKING yes ____ pack per day no
MOUTH dentures ulcers halitosis inflamed NECK lumps pain swelling BREAST lumps pain swelling LUNG chesty wheezing
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PHYSICAL EXAMINATION
Indicate on diagram the following abnormalities : bruises, decubites ulcer,laceration, discoloration
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NURSING DIAGNOSIS
ACTUAL PROBLEM
1 2 3 4 POTENTIAL PROBLEM
1 2 3 4
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MRN:______________________
Rationale evaluation
2.
2.
3.
3.
Subjective data: 4 4.
Objective data:
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