Professional Documents
Culture Documents
Nim : 16037140947
1. NUTRITION
Diet: Purred
Recent weight changes: Yes
Supplements: Yes
Conditions affecting eating, chewing, or swallowing: No
Monitoring required at mealtimes: No
Fluids Monitoring: Yes Restricted
Mocous membranes: Moist
Skin turgor: Fair
Coment:
Food is better cooked until tender and served at temperatures that are neither too hot
nor cold so as not to stimulate the imposition
Better food is provided often but in small portions
When given for long periods or in special circumstances, it should be accompanied
by vitamin and mineral supplements, or formula foods.
2. ELIMINATION
Bladder Incotinence : Occasional (less than daily)
Bowel Incotinence: Occasional (less than daily)
Incotinence management techniques: Yes
Bowel sounds present: Yes
Constipation: Yes
Ostomies:
Coment: Elimination of alvi. Clients may experience constipation due to prolonged
bed rest. While urine elimination is not disturbed, only the color of urine into brownish
yellow. Clients with typhoid fever occur an increase in body temperature resulting in a
lot of sweat out and feel thirsty, so it can increase the body fluids.
3. SENSORY
Vision: Normal
Hearing: Normal
4. MUSCULOSKELETAL
Mobility: Normal Assistive Devices: No
ROM: Limited
Motor Development: Tremor
ADLS:
Eating: S, Bathing: S, Dressing: S
5. SKIN
Rash
Skin Intact: Yes
Special Care or Monitoring: Yes
6. NEURO
Sensation: Intact
Pain: Daily
Vebal Response: Confused
Aphasia: Expressive
Memory Deficits: No
Impaired Desision-making:
Sleep Aids: No
Sleep Pattern: Sleep not well
Seizures: No
7. CIRCULATION
History:
Pulse: Regular
Skin: Pink
Edema: Yes Pitting: Yes
8. RESPIRATION
Respirations: Irregular
Breath Sound: Right (clear), Left: (clear)
Shortness of Breath:
Respiratory Treatments: None
9. DENTAL
Own Teeth
Dental Hygiene: Good
10. PSYCHOSOCIAL
Self Injurious Behavior: No
Agressive Behavior: No
Behavior: Calm
Answer Question: Slowly
Delusions and/or Hallucination: No