Adult Health Nursing-Clinical-2
(Appendix B)
Medical – surgical Nursing-II
Comprehensive Nursing Care Plan
. Student Profile:
Student Name: I.D. No.:
Instructor: Date:
Patient Profile: (2)
Patient's Name: Age: Gender:
Ward: Room No: Bed No:
Admission Date:
Medical / Surgical diagnosis:
Date of Surgery:
Diet:
Physical Limitations:
Allergies:
Safety Precautions:
I.V. Therapy:
Religion:
Communication Problems:
Health History:
1. Current Health Status: (Chief Complaint and History of Present Illness)
(10)
2. Past health History (Hospitalizations, serious accidents, injuries, illness,
or treatment) (2)
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3. Family History(family tree or paragraph ) (2)
4. Health perception/ health Management (4)
Perception of quality of health
Perceived control and management of health
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Review of Body System (5)
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Physical Examination of the affected system: (10)
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Special Diagnostic Procedure (5)
Laboratory Investigation
The Test The Results Normal Range Interpretation
Other Procedure (Including the result, and your interpretation):
……………………………………………………………………………………………
……………………………………………………………………………………………
Medications: (5)
Drug Name Dose and Rout Classification Side effect Nursing
Frequency considerations
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Significant Data (10)
Subjective Data (5) Objective Data (5)
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Analysis (10) Planning (10) Implementation (20) Evaluation (5)
(Nursing Diagnosis) (Outcome) (Nursing Actions) (Rational for Nursing Actions)
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Analysis (10) Planning (10) Implementation (20) Evaluation (5)
(Nursing Diagnosis) (Outcome) (Nursing Actions) (Rational for Nursing Actions)
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9 .Guidelines for Review of Body Systems (4 points)
Use the following format for review of body systems to complete all your assignments:
Note: Abnormal findings should be detailed according to the PQRST rule.
GENERAL:
] [Recent weight changes.
] [Fever/ child.
] [Malaise/ general weakness.
] [Mood changes
SKIN, HAIR, AND NAILS:
] [Rashes
] [Lesions
] [Itching
] [Color change
] [Dryness
] [Brittle
] [Creaking
] [Others
HEAD
] [Headache
] [Seizure
] [Fainting
] [Head injuries
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] [Dizziness
EYES:
] [Changes in vision
] [Blindness
] [Cataract
] [Diplopia
] [Redness
] [Pain
] [Photophobia
] [Glasses (last exam date and results)
] [Contact lenses (type)
] [Glaucoma
] [Drainage
] [Infection
] [Others
EARS:
] [Difficulty in hearing/ deafness
] [Tinnitus
] [Vertigo
] [Infection
] [Discharge
] [Others
NOSE AND SINUSES:
] [Nasal stuffiness
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] [Frequent colds
] [Hay fever
] [Nose bleeds
] [Sinus troubles
MOUTH, PHARYNX, AND NECK:
] [Bleeding from gums/teeth
] [Oral infection
] [Dental problems
] [Dentures (last exam, time and results)
] [Hoarseness
] [Swelling in neck
] [Frequent sore throats
] [Lumps in neck
] [Dysphagia
] [Stiffness in neck
] [Others
BREASTS:
] [Prurutus, pain, lumps
] [Nipple discharge
] [Dimpling of skin
] [Enlargement (gynecomastia)
] [Performance of self-breast exam
] [Mammograms (date, results)
] [Steroids
] [Others
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LUNGS:
] [Shortness of breath
] [Dyspnea on exertion
] [Orthopnea
] [Pain with respiration
] [Cough
] [Sputum (color, frequency, quantity)
] [Hemopteysis
] [Wheezing
] [Cyanosis
] [Pneumonia
] [Bronchitis
] [Emphysema
] [Asthma
] [TB test (results and date)
] [ TB exposure
] [Chest X-ray (date and results)
] [Others
HEART:
] [ Heart troubles
] [High blood pressure
] [Heart murmurs
] [ Paroxysmal nocturnal dyspnea
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] [Chest discomfort
] [Palpitations
] [Syncope
] [Rheumatic fever
] [Coronary Artery disease
] [Heart attack
] [ECG (results and dates)
] [Other heart tests
] [Others
PERIPHERAL:
] [Edema
] [Swelling/ pain calves
] [Pain/ ulcerations or discoloration of extremities
] [Cramps
] [Varicose veins
] [Others
GASTROINTESTINAL:
] [Nausea
] [Vomiting
] [Hematemesis
] [Indigestion/ heart burn
] [Abdominal pain
] [Jaundice
] [Hepatitis
] [Melena
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] [Clay colored stools
] [Incontinence
] [Diarrhea
] [Change in bowel habit
] [Constipation
] [Hemorrhoids
] [Excessive gas
] [Hernia
] [Ulcer
] [Gall bladder stone/ colic
] [Pancreatic disease
] [Others
URINARY:
] [Frequency
] [Urgency
] [Infection
] [Dysurea
] [Nocturia
] [Hematuria
] [Stream site and force
] [Hesitancy
] [Incontinence (stress, urge, dribbling)
] [Others
MALE GENITALIA:
] [Discharge
] [Genital lesions
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] [Testicular pain/ mass
] [Syphilis positive serology
] [Gonorrhea
] [Sexual problems
] [Others
FEMALE GENITALIA:
] [Vaginal discharge
] [Prurits
] [Génital lésions
] [Painful intercourse
] [Post menstrual bleeding
] [Post coital bleeding
] [Pap smear ( results, dates)
] [Others
ENDOCRINE:
] [Heat and cold intolerance
] [Thyroid problems
] [Neck Surgery
] [Diabetes
HEMATOPIETIC
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] [Abnormal bleeding/ bruising
] [Anemia
] [Transfusions
] [Leukemia
] [Blood type
] [Others
SPIN AND EXTREMITIES: MUSCOLOSKELETAL
] [Arthritis
] [Joint stiffness
] [Joint swelling
] [Joint pain
] [Muscle weakness
] [Muscle cramps
] [Backache
] [Limited ROM
] [Others
SPIN AND EXTREMITIES: NEUROLOGICAL
] [Paresthesia/ numbness
] [Paralysis
] [In coordination
] [Disturbed balance
] [Fainting (LOC)
] [Blackouts
] [Tics
] [Tremors
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] [Spasms
] [Others
PSYCHIATRIC: (Problems in the following areas):
] [Spouse
] [Family
] [Peers
] [Insomnia
] [Depression (interfering with ADL's)
] [Anxiety interfering with ADL's)
] [Mood swings
] [Delusions
] [Hallucinations
] [Eating, sleeping, memory problems
[ ]Others
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