ELEVI : __________________

__________________

PREZENTARE DE CAZ
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Greutate:______ KG
Temperatur: ____grade C
Puls: ______batai/ minut
T.A..: ___/____mm Hg

A. CULEGEREA DATELOR
1. Date relativ stabile
Domnul/a._____________ n vrst de______ ani, sex ________, _______
Caracteristici individuale : rasa_______, religie_______________,______________, ________________
Elemente biografice
- ___________________________________________________________________________________________________
- ___________________________________________________________________________________________________
- ___________________________________________________________________________________________________
- ___________________________________________________________________________________________________
Elemente relaionale i fizice
- grupa sanguina_____, Rh______
- ___________________________________________________________________________________________________
Reeaua de susinere
- ___________________________________________________________________________________________________

2. Date variabile
Greutate: ______ KG
Temperatur: _______grade C
Puls: ______ batai/ minut
T.A..: ___/_____mm Hg
______________________________________________________________________________________________________
Condiii psiho- sociale:
- ___________________________________________________________________________________________________
- ___________________________________________________________________________________________________

B. ANALIZA I INTERPRETAREA DATELOR

1. Dimensiunea bio- fiziologic
Elemente de independen
- ___________________________________________________________________________________________________
- __________________________________________________________________________________________________
Elemente de dependen
Temperatur: ______ grade C;
Puls: ______/ minut;
T.A..: ___/___ mm Hg.
2. Dimensiunea psiho- social
Elemnte de independen
- __________________________________________________________________________________________________;
- ___________________________________________________________________________________________________
Elemente de dependen
- ____________________________________________________________________________________________________;
- ____________________________________________________________________________________________________
3. Dimensiunea cultural -spiritual
Elemnte de independen
- ___________________________________________________________________________________________________;
- ___________________________________________________________________________________________________
Elemente de dependen
- ___________________________________________________________________________________________________.

NEVOILE PRIORITARE ALE PACIENTULUI:

1.___________________________________________________________________________________________________
2.___________________________________________________________________________________________________
3. __________________________________________________________________________________________________
4.____________________________________________________________________________________________________
5.____________________________________________________________________________________________________
6.____________________________________________________________________________________________________
7. ___________________________________________________________________________________________________
8. ___________________________________________________________________________________________________
9.___________________________________________________________________________________________________

Nevoia
fundamental
1.

Diagnostic de
ngrijitre
P-

Obiective

Intervenii autonome
-

E-

Intervenii delegate

Evaluare

S-

2.

P-

E-

S-

3.

P5

E-

4.

P-

E-

S-

5.

P-

E-

S-

P6.

E-

S-

7.

P-

E-

S-

8.

P-

E-

S-

P-

E-

S-