Nursing dynamic assessment of the patient

SAINT PETERSBURG

HEALTH COLLEGE

NURSING CASE HISTORY

Medical diagnosis:

Subject: nursing in therapy

Student:________________________

2013-2014 academic year

FULL NAME.__________________________________________________________________________________________________

Age (full years) ________________________________________________________________________________________

Date and time of admission _________________________________________________________________________________

Date and time of issue ___________________________________________________________________________________________

Types of transportation (underline) on a wheelchair, on a chair, can walk

Side effects of drugs ________________________________________________________________________________________________________________________________________________________________________________________________________________

(name of the drug, nature of side effects)

Permanent residence______________________________________________________________________________

Place of work, profession or position __________________________________________________________________________________________________________________________________________________________________________________________________________________________

(for students, place of study, for disabled people, type and group of disability)

Family status______________________________________________________________________________________

Sent to the hospital for emergency indications (underline)

Yes, no, planned hospitalization

Subjective examination

1. reason for contact

The patient’s opinion about his condition

Expected Result_____________________________________________________________________________________

2. source of information (underline) patient, family, medical documents, medical staff,

other sources ___________________________________________________________________________________________

the patient’s ability to communicate yes, no.

Speech (underline) normal, absent, impaired

Vision (underline) normal, reduced, absent

Hearing (underline) normal, reduced, absent

3.complaints of the patient

Upon enrolment_________________________________________________________________________________________

At present______________________________________________________________________________________

4. medical history (when it started, how it started, how it proceeded, ongoing research, treatment, its effectiveness) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. life story

The conditions in which he grew and developed (living conditions) ______________________________________________________________

Working conditions, occupational hazards, environment __________________________________________________________________________

Transmitted diseases, operations ________________________________________________________________________________________________________________________________________________________________________________________________________________

Sexual life (age, contraception, problems) ________________________________________________________

Gynecological history (onset of menstruation, frequency, soreness, profusion, duration, number of pregnancies, abortions, miscarriages, menopause-age)

Allergic history ________________________________________________________________________________

Features of nutrition ___________________________________________________________________________________________

Does the patient smoke (from what age. Number of cigarettes per day) ____________________________________________________

Attitude to alcohol (underline) does not use, moderately, excessively

Spiritual status (culture, beliefs, entertainment, leisure, moral values)

Heredity________________________________________________________________________________________________________________________________________________________________________________________________

Objective research (underline as appropriate)

1. consciousness is clear, confused, absent.

2. position in bed active, passive, forced.

3. behavior is adequate, inadequate.

4. mood (emotional state) calm, withdrawn, sad, etc.

5. growth ____________________________

6. weight _____________________________

7. temperature _____________________

8. condition of the skin and mucous membranes

– turgor, humidity

color (hyperemia, pallor, cyanosis, jaundice)

defects (pressure sores) yes, no.

edema yes, no.

9. lymph nodes (enlarged) yes, no.

10. musculoskeletal system

skeletal deformity yes, no.

deformity of the joints yes, no.

muscle atrophy yes, no.

muscle strength _______________________

11. respiratory system

voice changes yes, no.

NPV, shallow, deep breathing .

rhythmic breathing yes, no.

the nature of dyspnea is expiratory, inspiratory, mixed.

chest excursions symmetry yes, no.

cough yes, no.

sputum yes, no.

the nature of sputum is purulent, hemorrhagic, serous, foamy.

smell (specific) yes, no.

lung percussion clear pulmonary sound, boxy, dullness, dullness.

auscultation of the lungs

vesicular breathing , hard wheezing yes, no.

12. cardiovascular system

pulse (frequency, tension, rhythm, filling, symmetry) ______________________________________________________________________________________________________________________________________________

pulse deficit ________________________________________________________________

auscultation of the heart

BP on both arms left __________________ right _______________________________

edema yes, no.

13. gastrointestinal tract

Appetite is not changed, reduced, absent.

Swallowing is normal, difficult.

Removable dentures yes, no.

the tongue is overlaid yes, no.

vomiting yes, no.

stool is formed, constipation, diarrhea, incontinence (admixture of mucus, blood, pus).

belly

the usual form yes, no.

increased flatulence, ascites. asymmetrical yes, no.

pain on palpation yes, no. stressed yes no.

14. urinary system

sword emission is free, difficult, painful, speeded up.

the color of urine is normal, changed (hematuria, “beer”, “meat slops”)

transparency yes, no.

15. endocrine system

the nature of hair growth male, female.

distribution of subcutaneous fat male, female.

visible enlargement of the thyroid gland yes, no.

signs of acromegaly yes, no.

16. nervous system

– normal sleep , insomnia, restless.

duration __________________________________

sleeping pills required yes, no.

tremor yes, no.

gait disturbance yes, no.

paresis, paralysis yes, no.

tendon reflexes are normal, pathological.

Sensitivity preserved, impaired.

Basic human needs (impaired underline)

Breathe, eat, drink, excrete, move, maintain condition, maintain temperature, sleep, rest, dress and undress, be clean, avoid danger, communicate, worship, work ((play, learn).

Patient problems (real) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Appointment sheet

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing analysis of laboratory and instrumental data

(compare with normative indicators, norm/pathology)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing epicrisis

(a brief description of the patient’s problems during his stay in the hospital, long-term goals and the main ways to solve them during aftercare)

The patient had problems upon admission __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

At discharge ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Long-term goals________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The main solutions for aftercare at home ___________________________________________

Nursing dynamic assessment of the patient

FULL NAME. patient ________________________________________________________________________

the date
day in the hospital
Consciousness: clear
confused
Is absent
Sleep: normal
disturbed
Temperature
Skin covers:
Without changes
Defects
Pale, hyperemia, cyanosis, jaundice
Respiration (RR)
Pulse
HELL
For diabetics: blood sugar levels
The weight
Daily diuresis
Meal:
On one’s own
Help Wanted
Chair
Urination
Bathing: shower
Bath
Partially in bed
Complete independence
Issues Identified
Examination for pediculosis
Visitors

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