Beruflich Dokumente
Kultur Dokumente
I. VITAL INFORMATION Name: Age: Sex: Address: Civil Status: Date and Time Admitted: Chief Complaint: Ward: Bed No.: Allergies: Religious Affiliation: Physicians Initial: Impression/Diagnosis: Pre-op Diagnosis: Post-op Diagnosis: Surgical Operation Performed: Days of Post-op: Date of Interview: Informant: Relationship to Patient:
II. CLINICAL ASSESSMENT II. A.: NURSING HISTORY 1.History of Present Illness a. Usual Health Status
b. Chronologic Story
c. Disability Assessment
b.Immunizations
c. Allergies
f. Medications
5. Patterns of Functioning a. Breathing Patterns Respiratory Problems: Usual Remedy: Manner of Breathing: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.
c. Sleep Patterns Usual bedtime: Number of pillows: Bedtime Rituals: Problems regarding sleep: Usual remedy: d. Drinking Patterns Kinds in Fluid in 24 hours/ Amount in mL or Number of Bottles: Kind of Fluid Amount
Lunch
Dinner
Snacks
h. Personal Hygiene 1.Bath Type: Frequency: Time of Day: 2.Oral Care Frequency: Care of Dentures: 3.Shaving: Frequency: 4.Use of Cosmetics:
i. Recreation:
j. Health Supervision:
II. B.: CLINICAL INSPECTION II.B.1. Vital Signs: T= BP = II.B.2 Height: II.B.3.Weight: Date and Time taken: PR = RR =
4. Personality Style:
8. Mental Status Examination (Circle the correct words. Include a short description of client for each area assessed.) APPEARANCE Neat Clean Dishevelled inappropriate makeup Poor Grooming Erect Posture
Others: ___________________
Others: __________________
Others: ________________________
MOOD/AFFECT Appropriate Angry Description: Labile Hopeless Flat Depressed Worried Anxious
Others: _________________
THOUGHTS Appropriate Delusions Description: Low Phobias Self-Esteem Suicidal Ideations Hallucinations
Others: ______________________
P/I