Ncp-adult[1]

ILIGAN MEDICAL CENTER COLLEGE San Miguel Village, Pala-o, Iligan City

COLLEGE OF NURSING, MIDWIFERY & HEALTH AIDE

NCP BOOKLET CASE METHOD APPROACH GUIDE TO PATIENT CARE ANANLYSIS

STUDENT: _________________________________________________ ______________

YEAR LEVEL: ___________________

HOSPITAL/ WARD: __________________________________________ __________________________________

INCLUSIVE DATE OF EXPOSURE:

CLINICAL INSTRUCTOR: _____________________________________ ________________________________________________________

RATING:

GROUP NO:

PATIENT ASSESSMENT DATABASE

HEALTH HISTORY

Name

: _________________________________________________

Address :________________________________________________

Age

: _________________________________________________

Inclusive Date of Confinement : ______________________________

Sex

: _________________________________________________

Admission Date & Time : ___________________________________

Nationality

: _________________________________________________

Discharge Date & Time : ____________________________________

Civil Status

: _________________________________________________

Attending Physician

Religion

: _________________________________________________

Initial Diagnosis : __________________________________________

: ______________________________________

Highest Educational Attainment :____________________________________

Final Diagnosis : __________________________________________

Occupation

Source of History : _________________________________________

: ________________________________________________

Source of Income : _______________________________________________

Reliability of Historian : _____________________________________

Rank in the Family : ______________________________________________

Chief Complaint : __________________________________________

I. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN A. Present Health Status

B. Past Health Status b.1

General Health _____________________________________________________________________________________________________________________

b.2

Prophylactic Medical/ Dental Care _____________________________________________________________________________________________________________________

b.3

Childhood Illness _____________________________________________________________________________________________________________________

b.4

Immunizations ____________________________________________________________________________________________________________________

b.5

Major Illness/ Hospitalizations ____________________________________________________________________________________________________________________

b.6

Current Medications Prescribed

Non – Prescribed ____________________________________________________________________________________________________________________ b.7

b.8

Allergies Ingestants ______________

Injectants_________________ Inhalants_____________________ Contactants ___________________

Alcohol________________

Caffeine __________________ Drugs _______________________ Tobacco ______________________

Habits

b.9

Family Health History (Genogram) Legend: X

- male

CA

- cancer (specify)

Y

- female

DM

- diabetes mellitus

+

- deceased

PTB

- pulmonary tuberculosis

AW

- alive & well

HPN

- hypertension

*

- patient

MI

- myocardial infarction

F

- father

SUI

- suicide

M

- mother

RF

- renal failure

B

- brother

CVA

- cerebrovascular accident

S

- sister

?

- unknown

C

- children

Additional – if applicable

II. NUTRITION – METABOLIC PATTERN A. Appetite B. Usual Daily Menu Breakfast _____________________________________________

Dinner _____________________________________________

Lunch ________________________________________________

Snacks _____________________________________________

C. Dentition _________________________________________________________________________________________________________ D. Metabolic ( wt. gain/ loss) ___________________________________________________________________________________________ III. ELIMINATION PATTERN A. Bowel _____________________________________________________________________________________________________________ B. Bladder ____________________________________________________________________________________________________________

IV.

ACTIVITY – EXERCISE PATTERN A. Self – Care Ability _________ Feeding

__________ Toileting ____________ Dressing ___________ Home Maintenance

_________ Bathing

__________ Bed Mobility __________ Grooming __________ Cooking

Legend:

Function eve’s Code O

- Full Self Care

I

- Requires use equipment of device

II

- Requires assistance or supervision

III

- Requires assistance or supervision from another personal equipment device

IV

- Is dependent and does not participate

B. Oxygenation/ Perfusion b.1

Chest X – Ray ( If any )

b.2

Cardiac Risk Factors ( If applicable ) Positive

Negative

Not Known

1. Sedimentary life style

_______

_______

________

2. Hypertension

_______

_______

________

3. Obesity

_______

_______

________

4. Hyper-vigilant personality

_______

_______

________

5. Hyper-lipidemia

_______

_______

________

6. Family history of heart disease

_______

_______

________

7. Diabetes

_______

_______

________

8. Cigarette smoking

_______

_______

________

___________ Shopping

______________ General Mobility

V.

SLEEP & REST PATTERN

VI.

COGNITIVE – PERCEPTUAL PATTERN A. Hearing __________________________________________________________________________________________________________ B. Vision ___________________________________________________________________________________________________________ C. Sensory Perception ________________________________________________________________________________________________ D. Learning Style ____________________________________________________________________________________________________

VII.

SELF – PERCEPTION/ SELF-CONCEPT PATTERN

VIII.

ROLE – RELATIONSHIP PATTERN

IX.

SEXUALLY – REPRODUCTIVE PATTERN

X.

COPING-STRESS TOLERANCE PATTERN

XI.

VALUE – CENTER PATTERN

PHYSICAL EXAMINATION

I.

GENERAL SURVEY

II.

VITAL SIGNS

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

Temperature

_____

_____

_____

_____

_____

Pulse Rate/ Cardiac Rate

_____

_____

_____

_____

_____

Respiratory rate

_____

_____

_____

_____

_____

Blood Pressure

_____

_____

_____

_____

_____

III.

INTEGUMENTARY A. Skin

: Color __________________

Abnormalities ______________________________

B. Mucous membrane

: _______________________

C. Nails

: _______________________

D. Hair

: Distribution ___________________

Appearance _______________

Hygiene ____________________

IV. HEENT Head

:

Size _____________

Shape ____________________

Eyes

:

Color ( optic disk & conjunctive ) ________ Visual acuity _______ Pupil Response _________ Accomodation _______________

Ears

:

Symmetry ________________ Discharge/ Growth ______________ Hearing Ability __________________________________

Nose

:

Mucosal condition __________________________________ Discharge Growth ______________________________________

Mouth/ Throat/ Pharynx/ Teeth: ( Color/ Lesions/ Smoothness/ Presence of Cavity ) _________________________________________________ Face

:

Symmetry _____________________________________________ Facial Musculature ________________________________

V.

Neck / Lymph Nodes Symmetry

VI.

VIII.

: _________________________________

Breast and Axillary areas

: ___________________________________________

Abnormal (please specify) _________________________________

:

Symmetry _________________________

Growth _____________________

Discharge _________________________

Lymph Nodes ________________

Retraction _________________________

Cardiovascular Normal : ________________________________

Abnormal

(S1 S2 )

: ____________________________________

(extra sounds) :

Rhythm _________________________________ IX.

Growth

Pulmonary ( Breath & Sounds ) Normal

VII.

: _________________________________

Rate

Murmurs

___________________________________________

Peripheral / vascular Peripheral Pulse ( state if equal – bilaterally )

X.

Grade ____________

Temporal ____________________

Legend : Peripheral Pulse Scales

Grade ____________

Carotid ______________________

0 – Absent

Grade ____________

Bronchial ____________________

1 – markedly diminished

Grade ____________

Radial _____________________

2 – moderately diminished

Grade ____________

Femoral _____________________

3 – slightly diminished

Grade ____________

Popliteal _____________________

4 – normal

Grade ____________

Posterior Tibialis ______________

Grade ____________

Dorsalis Pedis _________________

Abdomen General contour_________________________________

Tenderness

_______________________________

Bowel Sounds _________________________________

Abdominal Sounds ____________________________

LABORATORY DATA / DIAGNOSTIC STUDIES A. LABORATORY EXAMINATIONS

RESULTS

NORMAL VALUES

SIGNIFICANCE

A. DIAGNOSTIC EXAMINATIONS

RESULTS

NORMAL FINDINGS

SIGNIFICANCE

COLLABORATIVE PLAN OF CARE Medications Standing Orders Brand Name/ Generic Name

Date/ Dosage/ Frequency

Indications

Action/ Mechanism of Action

Side Effects

Nursing Precautions

NURSING DIAGNOSIS DEVELOPED IN CARE PLAN

CUES

PATHOPHYSIOLOGIC

NURSING

BASIS

DIAGNOSIS

INTERVENTION PLAN/ OBJECTIVE

(Independent/ Dependent/ Interdependent)

RATIONALE

EVALUATION