dosar de ingrijire
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Spitalul: Medic:Sectia:
Dosar de ingrijire
Date de identitate
Numele : Prenume :Varsta : Sexul : M /F Domiciliul-loc :Strada: Nr.: Bl.: Sc.: Et.: Ap.: Judet:
Date despre spitalizare
Data internarii – anul: luna: ziua: ora:Data externarii –anul: luna: ziua: ora:Motivele internarii:
Diagnosticul la internare:
Situatia familiala si sociala
Situatia familiala: Nr. copii:Situatia sociala: Profesia:Conditii de locuit:
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Persoane cu care se ia legatura
Nume: Prenume:Adresa: Tel.:Nume: Prenume:Adresa: Tel.:
Antecedente
Heredo-colaterale:
Personale-fiziologice:
Personale-patologice:
Factorii de risc legati de modul de viata:
Istoricul bolii extras din examenul medical la internare
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Prescriptii medicale la internare
Tratamentul:
Examinarii:
Regimul:
Observatia initiala
Situatia la internare I: G: TA: P:T: R: Vaz: Auz:
Nevoi fundamentale01.A respira:
02. A bea, a manca:
03. A elimina:
04. A te misca:
05. A dormi, a te odihni:
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06. A te imbraca, a te dezbraca:
07. A-ti mentine temperatura in limite normale:
08. A fi curat, a-ti proteja tegumentele:
09. A evita pericolele:
10. A comunica:
11. A te recrea:
12. A fi util:
13. A invata:
14. A-ti practica religia:
Alergic la:
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Aspecte psihologice
Starea de constienta:
Comportament:
Mod de internare – singur salvare familia altulParticularitati:
Aspecte sociale
Mod de viata – singur de familie altulMediul (habitat) – rural urbanParticularitati:
Probleme sociale:
Interpretarea datelor
Nevoi nesatisfacute. Diagnostice de nursing initiale:
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Posibilitati de evolutie
Vindecare:Stabilizare, ameliorare:
Agravare:
Deces:
Comportament asteptat, in ce interval
Momente importante ale spitalizarii
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Obiectivul global
Nume: Prenume:Sectia: Diagnostic:
Alimente permise:
Alimente interzise
Preferinte alimentare:
Alimentatia
Data Ora Regimul alimentar Observatii
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Nume: Prenume:Sectia: Diagnostic:
Tratamentul urmat la domiciliu:
Tratament
Data Ora Prescriptii Medic Semnatura
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Nume: Prenume:Sectia: Diagnostic:
Examene biologice
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Nume: Prenume:Sectia: Diagnostic:
Examene paraclinice
Data Ora Examene cerute Medic Semnatura
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Nume: Prenume:Sectia: Diagnostic:
Parametri fiziologici
Data Ora Temp. Puls Resp. T.A. Diureza Scaun Semnatura
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Observatii/ Evolutie
Data Ora Observatii si interventii
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Concluzii generale
Evolutia nevoilor fundamentale, tratamentul si efectele, evolutia valorilor reexamenelor medicale, etc.
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Concluzii generale(continuare)
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Plan de nursing
SectiaBolnavul Diagnostic
Data Diagnostic de nursing
Obiective Data Diagnostic de nursing
Obiective
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Spital: Bolnav:Sectia: Diagnostic:
Plan de nursing
Data Diagnostic de nursing Actiuni Evaluare
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Recomandari la externareExplicarea acestora
Modul de externare – singur cu familia altulMijloc de transport:
Observatii la externare
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