Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Patients Age:
Pt. Diagnoses:
OBJECTIVE
Health perception:
General Appearance:
Race: Gender:
Age Group:
Body Build:
Stature:
Grooming:
Mental Status:
Signs of Distress:
Life style:
Health Maintenance:
Habits:
Use of alcohol:
Use of tobacco:
Other Recreational or OTC Drugs:
Vital Signs
Body Temperature:
Blood Pressure:
Pulse:
Respirations:
II.
Nutrition Metabolic
SUBJECTIVE
OBJECTIVE
Food Preferences:
Appetite:
Nutritional Impairment:
Inability to swallow?
Inability to chew?
Hair:
Inability to feed self?
Color:
Length:
Texture:
Distribution:
Scalp:
Allergies:
Oral mucous membranes:
Color:
Consistency:
Gums:
Skin:
History of Skin/Healing Problems:
Usual Hygiene Practices:
Nails:
Skin Care Aides:
Color:
Shape:
Texture:
Nail Bed:
Capillary refill:
Teeth:
Condition:
Color:
Current dietary intake:
Vitamins or Supplements:
Amount eaten:
Fluid intake during the day:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
III.
Elimination
SUBJECTIVE
OBJECTIVE
Urinary:
Frequency of voiding:
Mode:
Characteristics:
Frequency of voiding:
Problems:
Bowel/stool
Bowel Sounds:
Abdominal appearance:
Contour:
Symmetry:
Surface motion:
Drainage:
Amount:
Color:
Odor:
Consistency:
Characteristics:
Presence of heavy perspiration/diaphoresis:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
IV.
Activity Exercise
SUBJECTIVE
OBJECTIVE
Mobility aids:
Limitations in ability:
Use of diversional activities:
Diagnostic studies:
V.
Sleep Rest
SUBJECTIVE
OBJECTIVE
Sleep patterns:
Observe appearance:
Routine:
Sleep aides used:
Observe behavior:
Problems:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
VI.
Cognitive - Perceptual
SUBJECTIVE
OBJECTIVE
Developmental Level:
Insight:
Pain Assessment:
Memory:
Speech:
Paralanguage:
Articulation:
Sequencing:
Appropriateness of content:
Neurological:
Orientation:
Pupil reaction:
Grasp Strength:
Level of consciousness:
Perceptual Cognitive:
Hallucination:
Delusions:
Attention span:
Sensory:
Visual Impairment:
Auditory Impairment:
Auditory aide:
Other sensory impairments:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
Diagnostic studies:
VII.
Self-Perception Self-Concept
SUBJECTIVE
OBJECTIVE
Posture:
Eye contact:
Mood:
Affect:
Describe Affect:
Attitude:
Expressed feelings about self:
Self affirmation comments:
Self derogatory comments:
Appropriateness of behavior:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
OBJECTIVE
IX.
Sexuality - Reproductive
SUBJECTIVE
OBJECTIVE
Breasts: .
Areola:
X.
OBJECTIVE
Coping patterns:
Behavior patterns:
Support system:
Mood:
Appearance:
Affect:
Ability to reason and make sound decisions:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
XI.
Values Beliefs
SUBJECTIVE
OBJECTIVE
Health/illness beliefs:
Symbols of Faith:
Nursing Diagnosis:
1. (Ackley and Ladwig, 2011).
2. (Ackley and Ladwig, 2011).
3. (Ackley and Ladwig, 2011).
10
DISCHARGE NEEDS
Treatments:
Special care or needs:
Special teaching:
Follow up care or appointments: .
Life expectancy:
Rehabilitation: specify type:
Return to:
Diagnostic Studies:
Medical-Surgical Treatment:
11
Diagnostic Studies:
Medical-Surgical Treatment:
Diagnostic Studies:
Medical-Surgical Treatment:
12
CLINICAL COURSE
13
DIAGNOSTIC STUDIES
Lab studies and x-rays ordered:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate
to the patient):
Name of test:
Name of test:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate
to the patient):
14
Dose Range
Client Dose
Side Effects/Drug
interactions
Nursing
Considerations and
Contraindications
1.
Goal:
Actions with rationale: (Minimum of three)
1. A 2. A3. A-
RRR-
Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)
RRR-
Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)
RRR-
Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)