Professional Documents
Culture Documents
Ward No: 04
Week Focus: Nursing care plan & Physical Examination
Initials: Sana khan
Room/Bed No: 24
Religion: Islam
Age: 07 years
Sex: Female
D.O.A: 7-11-2016
Occupation: Nil
Medical Diagnosis:
Burn Injury
Patient
Marital Status:
Clinical Profile:
Chief Complain/Concern:
Client has come in hospital with major thermal burn and respiratory
distress.
Genogram Key
= Decreased.
35 years
( ) = Cause of death
= Adoption
(Vertical)
2 years
7 years
5 years
1 BD
1 BD
1 TDS
H. Review of Systems:
Patient has complained of weakness and fever.
I. Any Lab or diagnostic tests:
Complete Blood Count (CBC) test results:
Neutrophils
42.7%
Eiosinophils 5.9%
Basophils
1%
Lymphocytes 31.0%
Monocytes
19.3%
J. Identified Nursing Diagnosis:
2.
3.
ELIMINATION PATTERN
D. History Data & System in Review:
(Diarrhoea, constipation, bleeding, haemorrhoids, changes in bowel habit,
urinary retention, incontinence, dysuria, hematuria, flank pain, urgency,
frequency and hesitation)
Patient has complain of decrease urine output.
E. Any Diagnostic / Lab investigation:
No diagnostic or Lab test is conducted.
4.
History Data & System Review: (Cough, SOB, Wheezing, pain, hemoptysis)
Respiratory rate: 40 breaths/ mint
Patient has increased respiration rate that is difficulty in breathing and
shortness of breath.
CIRCULATORY STATUS:
History Data & System Review: (Palpitation, Angina, orthopnea,
thrombophelbitis, leg cramps)
Patient is observed with hypotension and decreased myocardial
contractility.
MUSCULOSKELETAL STATUS:
A. History Data & System Review:
(Joint stiffness, cramps, heat, redness, deformity, weakness, edema)
Patient has complain of joint stiffness and edema
5.
6.
7.
SEXUALITY REPRODUCTIVE
PATTERN
A. History Data & System Review:
8.
B. Draw an ECOMAP:
ECOMAP KEY
Siblings
Parents
Very strong:
Strong:
Normal:
Patient
Weak:
Interrupted:
----
No relationship:
Religion
9.
Parents reports that child feels anxious and low mood while talking about
her burn injury
11.
Comments:
Signature of Instructor