(Co-existing illnesses, smoker?, substance use: tobacco, alcohol, illicit drugs?)
Immunizations
Childhood Illnesses
Prior Hospitalizations
Past Surgeries
Home Medications
Allergies
Family Health History
Admission Medical Diagnosis
Today’s Medical Diagnosis
Pathophysiology:
Admission & Today’s Medical Diagnoses
Use your own words; provide citations using APA format (include page numbers).
Code Status
Treatments
Diagnostic Tests Result Abnormal? Significance
General/Constitutional:
Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct usual activities, exercise tolerance?
Skin/Breast:
Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
Breast lumps, tenderness, swelling, nipple discharge?
Eyes/Ears/Nose/Mouth/Throat:
Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury?
Vision, double vision, tearing, blind spots, pain?
Nose bleeding, colds, obstruction, discharge?
Dental difficulties, gingival bleeding, dentures?
Neck stiffness, pain, tenderness, masses in thyroid or other areas?
Cardiovascular:
Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication?
Respiratory:
Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats?
Gastrointestinal:
Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits?
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence, libido, potency, genital stores, discharge, venereal disease?
(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para):
Musculoskeletal:
Pain, swelling, redness, or heat of muscles or joints, limitation, of motion, muscular weakness, atrophy, cramps?
Neurologic/Psychiatric:
Convulsions, paralyses, tremor, incoordination, paresthesia’s, difficulties with memory of speech, sensory or motor disturbances, or muscular coordination (ataxia, tremor)
Predominant mood “nervousness” (define), emotional problems, anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations?
Allergic/Immunologic/Lymphatic/Endocrine:
Reactions to drugs, food, insects, skin rashes, trouble breathing?
Anemia, bleeding tendency, previous transfusions, and reactions, Rh incompatibility?
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy, growth, secondary sexual development, intolerance to heat or cold?
Review of Systems (ROS) for Current Health Problems
(Patient’s [or family’s, reporting nurse’s, or recent H&P] SUBJECTIVE description of health status for each body system)
Highlight, underline, or boldface the patient’s response; Write “denies” in the blank provided if patient does NOT
have these symptoms:
Erikson’s Stage of Development: (Identify and describe your patient’s stage of development)
S: SUBJECTIVE DATA
O: PHYSICAL EXAMINATION/OBJECTIVE DATA
Vital Signs: (TPR, O2 sat: RA or % of supplemental oxygen
General Survey/Appearance
Level of Consciousness (LOC):
Respiratory:
(Inspect, palpate, percuss, auscultate)
Cardiac:
(Inspect, palpate, percuss, auscultate)
Neurologic:
(Speech, reflexes, grips, sensation, gait)
Abdomen:
(Inspect, auscultate, percuss, palpate)
Renal/genitourinary:
(I/O)
Musculoskeletal:
(Inspect, palpate; measure strength)
Skin:
(Lesions, IV sites)
A: NURSING DIAGNOSIS [PES: Problem, etiology, & symptoms {if indicated}]; (Must have 2 and demonstrate which one is PRIORITY by HIGHLIGHTING)
P: PLAN:
Outcome(s) [What you want your patient to achieve]
Goal statement(s): [Must have subject, action verb, date/time, and performance criteria: AEB (as evidenced by)]
I: NURSING INTERVENTIONS: (for priority problem); use APA format to cite your references & include page numbers.
Rationale with reference:
2.
Rationale with reference:
- Rationale with reference:
- Rationale with reference:
- Rationale with reference:
E: EVALUATION: (Met outcome? AEB……..); also reflects what things you are going to monitor/measure to determine if the outcome has been met.
A: NURSING DIAGNOSIS (for secondary problem)
P: PLAN:
Outcome(s) [What you want your patient to achieve]
Goal statement(s): [Must have date/time and AEB (as evidenced by)] I: NURSING INTERVENTIONS: (for priority problem); use APA format to cite your references & include page numbers.
Rationale with reference:
2.
Rationale with reference:
- Rationale with reference:
- Rationale with reference:
- Rationale with reference:
E: EVALUATION: (Met outcome? AEB……..); also reflects what things you are going to monitor/measure to determine if the outcome has been met.
Sample Solution
