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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

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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