Академический Документы
Профессиональный Документы
Культура Документы
General
Family
Teach/Learn
Current Health History of present illness, knowledge of problem, perception of health and quality of life, limitations, management of limitations, health/life goals
Socialization
Pysch. Profile Self concept, current stress levels, coping mechanisms, emotional status, mood, appearance, affect
Race, language, religion, marital status, insurance, contact person, relationships, advance directives, reason for admission, date of admission, last hospitalization, occupation, past hospitalizations & surgeries, medical history, past injuries, allergies, geographic exposure
Family history of: MI, COPD, HTN, DM, TB, CA, arthritis, ETOH, Alzheimer's, hyperlidemia, obesity Self-Care Eating, hygiene, dressing, continence, toileting, mobility
Education level, developmental status, desire to learn, knowledge of condition, information you taught, barriers to learning, compensation for barriers, questions asked
Spiritual Beliefs/practices, how do they get through the difficult times, source of strength/hope, meaning and purpose of life
Sexuality How are touch needs met?, concerns, health related info (pap smear,
Mental/Cognitive LOC, orientation, retention/recall, judgement, three stage command, language, calculation, mental health,
appropriate behavior, facial expressions, attention span, memory, eye contract, posture, environment (home, work, interview)
Physical Exam
Integument Rashes, allergies, sores, jaundice, hair loss, nails, texture, birthmarks, moles, infections
Eyes Last exam, corrective lenses?,, itching, burning, tearing, blurring, spots, glaucoma, cataracts
Ears Pain, changes, infections, discharge, hearing aids, dizziness, tinnitus, how do they clean them, hearing test
Oral/Throat Teeth/gums, sore, bleeding, lumps, spots, toothaches, cavities, swallow, chew, dental wear, taste, cold sores, exam
Neuro Fainting,
Psychiatric Nervous,
Breasts/GYN Lumps,
stiffness, lymphadenopathy
discharge, pain, swelling, BSE, dimpling, changes, mammogram, STD, # of pregnancies, abortions, miscarriages, yeast infections, PMS, itching Hematological Anemia, bleeding, bruising, blood type, transfusions,
palpitations, HTN, murmurs, varicosities, fatigue, edema, pain, cramps, EKG, orthopenea
wheeze, sputum, pain, fatigue, CXR, asthma, bronchitis, pneumonia, TB, SOB
Gastrointestinal Appetite, weight loss/gain, nausea, vomiting, gas pain, stools, BM, ostomy, heartburn, enemas, diarrhea constipation, gall bladder
Urinary Frequency, pain, blood, usual pattern, hernia, discharge, STE (lumps, masses), STD
Endocrine polydipsia, polyuria, diaphoresis, temperature sensitivity, change in activity, heat/cold intolerance