This medical document contains information about a patient, including their name, age, room number, and chief complaint. Sections include nursing history, physical assessment of body parts, psychosocial/cultural/spiritual factors, diagnostic tests and exams with normal values and the patient's results. The document aims to collect clinical information to aid in the patient's diagnosis and treatment.
This medical document contains information about a patient, including their name, age, room number, and chief complaint. Sections include nursing history, physical assessment of body parts, psychosocial/cultural/spiritual factors, diagnostic tests and exams with normal values and the patient's results. The document aims to collect clinical information to aid in the patient's diagnosis and treatment.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online from Scribd
This medical document contains information about a patient, including their name, age, room number, and chief complaint. Sections include nursing history, physical assessment of body parts, psychosocial/cultural/spiritual factors, diagnostic tests and exams with normal values and the patient's results. The document aims to collect clinical information to aid in the patient's diagnosis and treatment.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online from Scribd
Name of Patient: Age: Room/Ward # Chief Complaint: N U R S I N G NURSING HISTORY P H I Y S I O L O P G I C P A
BODY PARTS
Date: Student Nurse: Physician: Diagnosis: A S S E S S M E N T PSYCHOSOCIAL/ CULTURAL SPIRITUAL DIAGNOSTIC TEST/EXAM NORMAL VALUES PATIENTS RESULTS SIGNIFICANCE
Drug/Dose/Route/ Frequency/Timing Classification/Me-Chanism of Action Indications/Contraindications/ Side Effects Principle of Care Treatment Evaluation