Академический Документы
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VITAL INFORMATION
Initials:
Age:
Sex:
Ethnic Group:
Marital Status:
Occupation:
Current Employment Status:
Insurance Coverage:
Date of Admission:
Diagnosis:
Reason for seeking Medical Assistance or Hospitalization:
Allergies:
Client’s Health History:
Family Health History:
B. Development
Identify client’s status as it relates to Erikson’s developmental phases (e.g. old
age), psychosocial stage (e.g. late adulthood) and developmental tasks (e.g.
letting go). Describe observation made.
C. Psychological
What is the client’s emotional state (e.g. depressed, shy, and angry)?
How does the client seem to be coping with illness? Is the client using any defence
mechanisms? Any maladaptive response noted? Any fear or anxiety noted (e.g.
crying or excessive complaining)?
Does the client seem disinterested or detached? Is the client able to express fears?
What is client’s perception regarding threats to body image and separation from
support system?
D. Physiological
1. Cerebral and Peripheral Innervation
Level of consciousness (degree of alertness); degree of orientation to time,
place, and person? If confused, describe specific behavioural responses:
memory, difficulty speaking or swallowing, or organizing sentences? Ability
to follow directions? Are grips equal in strength? Test for strength in lower
extremities and describe. Any tremors or shaking? Lack of coordination?
Any numbers or tingling? Convulsion movements? Response to sensation
and painful stimuli? Hyperesthesia? Any fainting? Signs of paralysis? Any
change in guilt?
Eyes: describe color of iris, sclera, and conjunctiva. Any evidence of
inflammation? Any mucus drainage or encrustations? Size and shape of
pupils? PERRLA? Consensual response? EOM? Strabismus? Describe
any evidence of visual ability or difficulty. Any edema of lids? Ptosis?
Ears: Describe any evidence of actual hearing ability or difficulty. Symmetry
of placement? Size? Any wax build up, drainage, or debris? Tinnitus?
Vertigo?
Diagnostic Studies: compare client values with normal values and describe
significance (e.g. LP, EEG, x – rays, CT Scan, myelogram, etc.)
2. Integumentary
Hair: Color? Length? Any evidence of loss? Vermin? Flakes? Eruptions on
scalp? Dull or shiny? Texture distribution? Debris? Oil or dry?
Nails: Color? Opacities? Shape (e.g. spoon nails, clubbing, etc.) length?
Any debris? Any ridges or cracks? Degree of brittleness? Growth pattern?
Skin: describe the actual color of the skin. Describe how it feels: warm,
cool, moist, dry? Any eruptions or scales? Rashes (describe, if present)
turgor? Elasticity (describe)? Scaling? Discolorations? Scars? If present,
describe the scars as well as the surrounding tissue (e.g. edema, redness,
etc.), even if it is healed. Describe all wounds: size (in cm) and shape,
location, or drainage. If the drainage is present, describe amount color,
odor, condition of surrounding tissue, etc. Is there a break in the integument
due to I.V.’s? If present, describe the status of the site (e.g. any redness,
swelling, drainage, tenderness, or heat). All descriptions must be clear,
complete, and detailed.
3. Oxygenation
Respiratory rate rhythm, depth? Identify client’s normal range (high and
low). How do your findings compare? Shape of chest? Is chest expansion
symmetrical? If not describe. Any shortness of breath, dyspnea,
orthopnoea? Use of accessory muscle? Nasal flaring? Is client a mouth
breather, chest breather, or abdominal breather? Any cyanosis? If present,
describe. Any cough? If present, when, how, frequent, type: dry or
productive (quantity, color, clarity of secretions produced)? Hemoptysis?
Respiratory chest pain? If present, when, severity, etc. assess for anterior,
posterior and bilateral breath sounds: what do you hear … rales, rhonchi,
wheezing, or friction rubs? Which lobes(s)? Is it heard upon inspiration,
expiration, or both? Is client receiving oxygen therapy? If so, amount?
Type? Per what method?
Diagnostic studies: client’s values. Normal values and significance (e. g. x-
rays, sputum C and S, ABG, CBC with differential, lung scan, etc.).
4. Circulation
Indicate and describe characteristics of all pulses, including apical (rate,
rhythm, strength); describe status of the vessel wall; pulse rate? Give
client’s normal rate (high & low) and compare your findings. Pulse deficit?
Blood pressure? Give client’s normal BP range (high & low) and make
comparison is there JVD? What are the results of your check for Homan’s
sign? Orthostatic hypotension? Any edema of extremities? If present,
which extremity (ies); describe specifically. Any chest pain (when?
Severity? Radiation? Describe specifically.) Palpitations? Capillary Filling
Time (must be less than 3 seconds)?
Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. CVP, serum cholesterol, SGOT, SGPT, LDH,
CPK, cardiac cath, EKG, chest x-ray, etc.)
5. Hematological
Any bleeding tendencies? Fatigue? Shortness of breath? Extreme
weakness? Skin color and turgor? Any palpable lymph nodes? Describe.
Transfusion required? If so, what type? Iron supplements required?
Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. bone marrow aspiration, RBC, WBC, platelet
count, HCT, HGB, coagulation time, serum iron, etc.).
6. Immunological
Any allergies? If so, describe the allergen and response. Childhood
diseases? Immunity: Active, Passive, Acquired, Natural, or Artificial,
Tonsils removed? Any swollen or tender lymph nodes? Any
immunosuppressive? Chemotherapy treatments?
Diagnostic Studies: compare client’s values, with normal values and
describe significance (e.g. Sedimentation rate, WBC, lymphocyte count, C
& S, biopsies, etc.).
8. Metabolism
Client’s temperature? Any intolerance to heat or cold? Changes in voice or
vision? Any weight changes? Any change in hair growth and texture?
Polydipsia? Polyuria? Polyphagia? Poor wound healing? Any fatigue?
Weakness: drowsiness? Palpitations? Nervousness? Irritability?
Insomnia?
Diagnostic Studies: compare client’s values with normal values and
describe significance (e.g. FBS, finger stick for glucose, serium TSH,
serum CA and Phos., (CT Scan, serum T3 and T4, radioactive iodine
uptake, etc.).
9. Urinary Elimination
Is client receiving I.V. therapy with electrolytes? What type? Any evidence
of electrolyte imbalance? Monitor client’s output pattern during your clinical
time. What is the amount and frequency of client’s usual output pattern?
Compare 8 hour and 24 hour intake and output patterns and balance. Does
the client experience intermittency, frequency, dribbling, urgency, or
retention (is there any distention at the suprapubic area)? Any
incontinence? If present, describe the urine; any discharge? Burning on
urination? Describe the urine: color, odor, and clarity? Any haematuria?
Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. serium electolytes, Co2, HCO3, UA, Bun,
creatinine. C & s, specific gravity, KUB, biopsies, IVP, etc.).
10. Reproductive
Female: Describe appearance of vaginal mucus membranes and labia.
Complaints of pain or discomfort? Any discharge? If present, describe
color, consistency, odor, amount, associated, bleeding, spotting, pruritus
or irritation of the skin, etc. any malformations? Age of menarche? Last
normal menstrual period? Number of pregnancies? Number of live births
any abortions/ any breast tenderness or discharge?
Male: development? Scars? Is client circumcised? Testes: relative size,
tenderness, or masses? Are both testicles descended? Any discharge? If
present, describe. Any malformations?
Diagnostics Studies: Compare client’s values with normal values and
describe significance (e.g. biopsies, pap smear, mammography, urine
hormone levels, etc.).
11. Musculoskeletal
Describe the overall muscle structure, build and tone. Any atrophy? If
present, where and to what degree? Any contractures? If so, which joints
specifically? Degree of ROM of all joints? If limited, then describe to what
degree (e.g. can extend elbow only 30 degrees). Ability to move self?
Gout? Smoothness of movement? Lordosis? Scoliosis? Kyphosis? Ant
fracture? If present, state location, presence of therapeutic devices (e.g.
traction, cast, etc.). How is movement affected? Ant swelling of joints,
redness, tenderness, or local heat?
Diagnostic Studies: Compare client’s values with normal values and
describe significance (e.g. x-rays, myelogram, arthogram, biopsy, serum
CA and Phos., etc.).
PLEASE EMPHASIZED ON THE IDENTIFIED SRESSORS WITHIN THE FOUR VARIABLES
AND THE SUBSYSTEMSWITHIN THE PHYSIOLOGICAL VARIABLE
I. VITAL INFORMATION
Initials: Age: Sex: Room #: Admission Date:
Medical Diagnosis:
Allergies:
Marital Status:
Family Structure:
Patient’s Race & Ethnic Origin:
What are the patient’s cultural and ethnic beliefs regarding health/healing practices:
Values and beliefs about cultural family roles, participation in care, decision making
and separation from family:
B. DEVELOPMENTAL VARIABLE
Expected developmental stage and tasks: (Erikson)
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the developmental variable. Remember to use NANDA terminology):
C. PSYCHOLOGICAL VARIABLE
How does the patient view this current illness:
Describe the patient’s emotional state and how they are dealing with the illness (e.g.,
depressed, shy, angry, sad, disinterest, insomnia, hypersomnia, etc.)
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing assessment
of the psychological variable. Remember to use NANDA terminology):
Memory (recent):
Remote:
Fainting/syncope:
Paralysis/weakness:
Abnormal gait:
EYES: Iris color:
Sclera color:
Conjunctiva color:
Evidence of inflammation, drainage or encrustation:
PERRLA:
Size of pupil:
Consensual response:
EOM:
Strabismus:
Describe evidence of visual difficulty:
Edema of lids:
Ptosis:
EARS: Describe any evidence of hearing difficulty:
Symmetry of placement:
Cerumen/drainage/debris:
Tinnitus:
Vertigo:
DRUGS:
LABORATORIES/DIAGNOSTIC STUDIES (CT Scan, MRI, Ultrasound, Culture and
Sensitivity, Blood Work, etc.:
Gerontological Changes (If your patient is 65 or over please indicate the expected age
related changes in this subsystem. (Highlight the changes that you observed in your
patient all the way throughout your nursing care plan).
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing assessment
of the physiological variable. Remember to use NANDA terminology):
2. INTEGUMENTARY
HAIR: Color:
Length/distribution:
Evidence of loss:
Infestation/debris, flakes/scalp eruptions:
Dull/shiny:
Texture:
Oily/dry:
NAILS: Color:
Shape/length:
Debris:
Ridges/cracks:
Growth pattern:
SKIN: Color:
Moist/dry:
Warm/cool/hot:
Rashes/eruptions/scales (Describe):
Turgor/elasticity (describe):
Bruises/discoloration:
Scars (describe the scars as well as the surrounding tissue such as edema,
redness, etc. even if it is healed:
Location:
Describe I.V. site (describe location, status, e.g., redness, swelling, drainage,
tenderness, heat or streaking):
DRUGS:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
3. OXYGENATION
Respiratory rate:
Rhythm:
Depth:
Shape of chest:
Expansion symmetrical (describe):
SOB/Dyspnea:
Orthopnea:
Nasal flaring:
Accessory muscle use:
Mouth/chest/abdominal breather:
Skin undertones: cyanosis (describe):
Cough:
When:
Frequency:
Type: Dry or Productive:
Sputum: description:
Chest pain (describe where, when and severity, etc.)
Pulse Ox reading:
DRUGS:
Gerontological Changes (If your patient is 65 or over please indicate the expected
age related changes in this subsystem. (Highlight the changes that you observed
in your patient all the way throughout your nursing care plan).
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
4. CIRCULATION
RATE RHYTHM STRENGTH/SCALE CHARACTERISTICS
Apical
Femoral
Radial
Pedal
Pulse: High and Low: Normal:
BP: High and Low: Normal:
Edema (describe location, type and degree):
Extremity temperature change:
Chest pain: (describe when, where, severity, radiation, etc.)
Fatigue:
Palpitations:
Thromboguards/Ted hose:
CRT (<2 seconds or >2 seconds):
DRUGS:
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
5. HEMATOLOGY
Bleeding tendencies:
Fatigue:
Dyspnea:
Petechiae:
Pallor, jaundice or cyanosis:
Weakness:
DRUGS:
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
6. IMMUNOLOGICAL
Allergies:
Describe the allergen/response:
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
Flatulence:
Nausea and/or vomitus (color, amount, odor, eructation):
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
8. METABOLISM – ENDOCRINE
Temperature: high: low: normal:
Polydipsia, polyuria or polyphagia:
Fatigue:
Delayed wound healing:
DRUGS:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
9. URINARY ELIMINATION
I.V. solutions:
Intake 8 hr.: 24 hr.:
Output 8 hr.: 24 hr.:
Fluid balance 8 hr.: 24 hr.:
Intermittency (urinary stream starts & stops):
Frequency (urinates how often?):
Dribbling (leakage):
Urgency:
Distention at the pubic arch:
Burning upon urination:
Urethral discharge:
Urine: color, odor, clarity:
DRUGS:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
10. REPRODUCTION
FEMALE:
Breast pain/discomfort: Masses:
Nipple discharge (describe): Breast dimpling:
MALE:
Circumcised: Scars:
Masses: Penis discharge (describe):
Any malformations:
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
11. MUSCULOSKELETAL
Describe the overall muscle skeletal structure and muscle tone:
If limited, describe the loss, such as, “can extend elbow 30 degrees”:
Amputations:
Describe altered mobility and assistive devises:
Smoothness of movements:
Lordosis/scoliosis or kyphosis:
Fractures (type & location):
DRUGS:
Gerontological Changes:
Nursing Diagnosis – (Indicate any nursing diagnosis that is based on your nursing
assessment of the physiological variable. Remember to use NANDA terminology):
III. NURSING ANALYSIS
I. THEORETICAL KNOWLEDGE BASE --- In your own words, discuss the
knowledge base
f. Describe the textbook nursing care management for a patient with this
illness
g. Compare and contrast your patient’s illness state with that of the
textbook.
b. INTERPERSONAL
c. EXTRAPERSONAL
2. Nursing Diagnosis
3. Nursing Diagnosis
4. Nursing Diagnosis
5. Nursing Diagnosis
6. Nursing Diagnosis
7. Nursing Diagnosis
8. Nursing Diagnosis