Report Gordons
Transcript of Report Gordons
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a N-205 2009INP 2012
Biographical Information:
Provider of Information: Relationship to patient:
Name:
Age: Birth date:
Birthplace: Gender:
Marital Status: Spouse’s Name: Age:
Occupation: Race:
Educational Level:
Reason for Seeking Care:
Admitting diagnosis: Current Diagnosis:
Advanced Directives: Living Will DNR
MPOA Requests information
Allergies (w/ reaction): (drug, food, latex)
Pain:Character:
Onset:
Location:
Duration:
Severity:
Pattern:
Associated Factors:
Past Health history:
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Problems at birth:
Childhood illnesses:
When? How long?
Immunizations:
MMR
Tetanus
Pneumonia
Flu
Polio
HIB
Hep B
Others:
Other illnesses:When? How long?
Surgeries: When? Post-op Treatment
Accidents:When? How long?
Intermittent Pain / Prolonged Pain:
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Family Health History: (Grandparents, Parents, Siblings, Children)
Cause of death Date Age
Grandfather(F)
Grandmother(F)
Grandfather(M)
Grandmother(M)
Father
Mother
Siblings:
Children:
Genogram:
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Health perception:
Health Status: Good Fair Bad
Satisfied with health status? Y N
Reason:
Tobacco/Cigarettes? Y N # of Packs/day:
Alcohol: Type:
How often? How much?
Street Drugs? Type:
How often? How much?
Chronic Diseases?When? How long?
Health Seeking behavior:
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Working Conditions: Excellent,Fair, Poor
______ safety
______ noise
______ space
______ heating/cold
______ water
______ ventilation
Living Conditions:Residence:
______ safety
______ noise
______ space
______ heating/cold
______ water
______ ventilation
Household members:
Problem areas:
Access to:
Grocery
Pharmacy
Clinic
Hospital
Transportation
Church Telephone
Medications before admission or current OTC medications used:meds # How often Reason
Alternative medications used:meds # How often Reason
Did you follow routine prescribed for med, diet, exercise? Why?
Problems with wounds/healing?
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Exercise: Type How often?
Ringing in the ears?y/n How often How long
Right
Left
Vertigo?How
often?Sincewhen?
How long doesit last?
How is itrelieved?
subjective
objective
Safety gear Seat belts Helmets
Padding Children’s seat
Suggestion for care?
Self examinations (breast/testicular)
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Nutrition
Weight fluctuations in last 6 months: Prefer to gain or lose?Gain
Loss
Appetite Good Fair Bad
Food Intolerances:food reaction
Dietary RestrictionsVoluntary
Health Regimen
Average Food intake in a day:Food / drink amount
Breakfast
Lunch
Dinner
In between
Food PreferencesLikes
Dislikes
Problems with (describe):
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Nausea
Vomiting
Swallowing
Chewing
Indigestion
Diarrhea
Constipation
Lifestyle: Active Sedate
Activities/Hobbies: How often is it done?
Chronic Health problems?
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Elimination
Frequency:
Same time each time? Y N time:
Strain during elimination?
Last bowel movement:
Changes in the last week:
Character of Stool Hard Soft liquid
Color of Stool brown black
yellow clay
variety:
Incontinence? Y NRelated to laughing, coughing or sneezing?
Recent travel:Where Inclusive Dates Remarks
Voiding Pattern: Frequency
Changes in pattern awareness to void urge to void
amount difficulty voiding
Color: Orange Bright yellow Light yellow
Smoky Dark
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Incontinence? Y NRelated to laughing, coughing or sneezing?Others:
Have time to go to the bathroom? Why/why not?
Any problem with:
Reaching the bathroom? Why/why not?
Retention? describe
Pain/Burning senasation? describe
Bladder Spasms? describe
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Activity / Exercise
Legend:0 = completely independent1 = requires device/eqpt
2 = requires assistance
3 = requires help frompeople/eqpt
4 = dependent
______ Feeding ______ Bath/hygien
e ______ toileting ______ grooming
______ ambulation ______ shopping ______ care of
home
______ mealpreparation
______ laundry ______ transportati
on
Who helps?
Is oxygen used at home? Y N
Pillow used in bed:
Fatigued? Y NWhen?
How often?
Describe
Climbing Stairs: How many steps/flights before feeling tired?
Walking: How far before feeling tired?
Falls?How often?
How bad?
Last Fall: Where: When:
Severity of Injury:
Weakness? Lack of Energy?
Difficulty doing things?
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Difficulty in Concentration?
Wheelchair management?
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Sleep – Rest Patterns
Sleep: _______ hrs/night
Naps:AM PM
Rested at waking?
Problems: Going to Sleep? Wakened at night?
Early Waking? Insomnia (describe)
Methods to promote sleeping:Meds:
Warm Fluids? What? How much?
Relaxation Techniques:
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Cognitive – Perceptual Pattern
Decision Making Easy Moderately Easy
Moderately Hard Hard
Inclined to make decisions Quickly Slowly Delayed
Knowledge Level:Current Problem
Current Therapy/Regimen
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Self-Perception / Self-Concept Pattern
Major concern right now?
Will this confinement alter the patient’s lifestyle?
Will this confinement alter the patient’s body image?
View of self: Positive Neutral Negative
Describe:
Problem with current situation
Perception of control 0 1 2 3 4 5None full
Assertion level 0 1 2 3 4 5Not very
Recent loss (social, physical, emotional)? Describe
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Role Relationship Pattern
Living with Spouse / Partner?
Relationship with spouse/partner is:
Parenting Skills: Not difficultaverage difficult
Recent losses (social, personal, psychological)
Will this confinement result in a loss?
Other diagnosis been made on the patient recently?
Does the patient express Sadness?
Will there be changes in the patient’s role in the family due to illness?
Social Activities: very active active limited none
Comfort in social situations 0 1 2 3 4 5Not very
Patient was caregiver? To whom?
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Sexuality
FEMALE:
Last menses:
Pregnancies para gravida
Menopause
Birth control
Vaginal discharges, bleeding, lesions
Pap smear Last pap smear
Mammogram (last)
STDInclusive dates Remarks
If raped:Physical symptoms experienced:
Emotional reaction:
Coping mechanism:
Rape Crisis Center: (via nurse?)
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Sexuality
MALE
Prostate problems?
Penile discharge, bleeding, lesions?
STDInclusive dates Remarks
BOTH
Problems with sexual functioning?
Satisfied with sexual relationship?
Admission to impact sexual functioning?
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Coping – Stress Tolerance
Stressful even in last year?
How do you handle stress? Poor 0 1 2 GoodDescribe:
Family support available?
Does the patient go to Counseling?
Are these support systems helpful?
Primary reason for admission?
Do you see a doctor as soon as there are symptoms? Why?
Caregiver:What is your understanding of care at home after admission?
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Values – Beliefs
Is the patient satisfied with life?
Does this admission interfere with any plans?
Religion:
Does this admission interfere with religious duties?
Religious restrictions (diet, treatment)
Does the patient desire counseling with minister, priest, rabbi, others?
Does Religion help in dealing with problems in the past?
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OBJECTIVE DATA
Vitals
site 1st __:____ 2nd __:____
Temperature
PR
RR - Abdominal
Diaphragmatic
Depth
BPWeight - lbs
Height - ft. ins.
Mental Status
Orientation:length of time
oriented /
disoriented
time
place
person
Sensorium: Alert Drowsy lethargic
stuporous comatose cooperati
ve
combative delusio
nal fluctuating
Appropriate response to stimuli:
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General Appearance
Body Build Ectomorph Mesopmorph Endomorph
Current body status:
Hair
Skin Color
Eczema
Turgor
Edema
Lesions
Skin Temperature cool warm
Nails
Body odor
Facial Expression
Eyes
Vision: Both Right Left
Focusing
Peripheral Vision
Pupils
Teeth
Dentures
Gums
Tongue
Mode of dressing
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References:
Handout: Gordon’s Functional Health Patterns
Carson, V., Shoemaker, N., Varcarolis, E. (2006) The Clinical Interview and Communications
Skills, Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 5th
Edition, (pp. 171-194), Missouri: Saunders Elsevier
Doenges, M., Moorhouse, M, Murr, A., (2006) Nurse’s Pocket Guide: Diagnoses, PrioritizedInterventions and Rationales, 11th Edition, Philadelphia: F.A. Davis Company
Kelley, J, Weber. J, (2007) Unit 2: Nursing Data Collection, Documentation and Analysis, and
Unit 3: Nursing Assessment of the Adult (Chapters on General Survey, Vital Signs,
Nutritional Assessment, Skin, Hair and Nails Assessment, Head and Neck Assessment,Eye Assessment, Mouth, Throat, Nose and Sinus Assessment), Health Assessment in
Nursing, 3rd Edition (pp. 27-74, 83-85, 119-142, 157-296), Philadelphia: Lippincott,
Williams & Wilkins