Documente Academic
Documente Profesional
Documente Cultură
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Health History
PHYSICAL ASSESSMENT PAGE 2
Neuro:________________________________________________________________________________________________________________
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Respiratory:__________________________________________________________________________________________________________
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Cardiovascular:______________________________________________________________________________________________________
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Gastrointestinal::____________________________________________________________________________________________________
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Genitourinary:_______________________________________________________________________________________________________
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Musculoskeletal:_____________________________________________________________________________________________________
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Endocrine:___________________________________________________________________________________________________________
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Integumentary:______________________________________________________________________________________________________
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Immune
System________________________________________________________________________________________________________
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As As As As
As evidenced evidenced evidenced evidenced
evidenced by by by by
by
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Priority Nursing
Diagnosis
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Supporting
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Assessment Data
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Long Term Goal
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________________________ Short Term Goal
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Priority Nursing Interventions
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#1 Intervention
#2 Intervention
#6 Intervention
Priority Nursing
Diagnosis
#5 Intervention #3 Intervention
#4 Intervention
Additional Nursing Interventions
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# Intervention
# Intervention
# Intervention
Priority Nursing
Diagnosis
# Intervention # Intervention
# Intervention
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Priority Nursing Diagnosis
#1 Intervention:
Rationale with reference & pg. #:
Evaluation:
#2 Intervention:
Rationale with reference & pg. #:
Evaluation:
#3 Intervention:
Rationale with reference & pg. #:
Evaluation:
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Priority Nursing Diagnosis
#4 Intervention:
Rationale with reference & pg. #:
Evaluation:
#5 Intervention:
Rationale with reference & pg. #:
Evaluation:
#6 Intervention:
Rationale with reference & pg. #:
Evaluation:
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References