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). PATIENT3S DE#OG-APHIC DATA
Name 6initials):0.P Date o A'mission& 2+/47/2413
Date o /ith& 4+/47/15*1 A!e& +2yo
Gen'e& Fe$a"e -ace& ndian
#aital Status& (ing"e -eli!ion& induis$
#ain Lan!ua!e o Communication& )a$i" and 8ng"is& Occupation& 9ne$p"oyed
*. PAST HISTO-Y
#e'ical&
sc&e$ic &eart disease
ypertension
ys"ipide$ia
(pina" stenosis
Pri$ary C( "y$p&o$a on c&e$ot&erapy,
acco$panied by sei;ure
Su!ical (nature & date of operation if applica%le):
Carpa" tunne" op recent"y
Famil1&
i"
Social&
i"
. C$--ENT HOSPITALI4ATION
-eason o Hospitali5ation&
Patient used to ad$it on 24/4+/2413 disc&arge on
22/4+/2413 < =ard '7, C"ass C, under 0 %or
abdo$ina" pain
Partia" sei;ures 6(i$p"e partia" sei;ures> :
ro!sy
i"atera" pupi"s di"ate
Ab"e to recogni;e p"ace, person but not ti$e
2 Respiration 6rate, patterns, nor$a"/abnor$a" breat& sounds, (P2>:
Respiratory rate: 1+ breat&s/$in
reat&ing pattern: Regu"ar
or$a" breat& sounds
(p2 144G
3 Circu"ation 6pu"se rate, b"ood pressure, apeB beat>
Pu"se rate: 14* beats/$in
"ood pressure: 13+/EE
(1(2 c"ear
' astrointestina" 6abdo$ina" assess$ent H pa"pation, percussion>:
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nspection
Abdo$ina": F"at, no signs o% distention
* (@in 6inc"udes &air nai"sI co"or, teBture, "esions, integrity>:
+ 0out& )&roat 6inc"ude "ips tongue H $oist/dry, condition o% teet&, dentures>:
E utrition 6eating patterns, appetite>:
7 8"i$ination: 9rinary 6patterns, incontinence, dribb"ing>:
5 8"i$ination: o!e"s 6patters, incontinence>:
14 Co$%ort 6pain assess$ent H use CAR), pain score>:
11 ("eep 6patterns>:
12 0obi"ity Acti#ity 6gait, ba"ance, ?oints>:
13 Psyc&osocia" econo$ic 66&ousing, education>:
1' (piritua"ity 6re"igion, re"igious practices>:
1* Ris@ Assess$ent 6%a"" pressure u"cer ris@>:
1+ t&ers:
9. #ASTE- P-O/LE# LIST (N$-SING"(!ist in order of priority / at least + nursing diagnoses / select from list of Nursing ,iagnoses inAppendix #)
Nusin! Dia!nosis& Actual Nusin! Dia!nosis& Potential
1
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:. N$-SING CA-E PLAN(,e*elop 0 nursing care plans from the master pro%lem list / use template inAppendix )
;. DISCHA-GE PLANNING
#ain Cae!i0e& Home e
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