CENTRUL DE EXAMEN : ŞCOALA POSTLICEALĂ ,, HENRI COANDĂ “

CONSTANŢA

PREZENTARE DE CAZ CLINIC

PENTRU PROBA PRACTICA A EXAMENULUI DE ABSOLVIRE

SPITALUL CANDIDAT
SECTIA
SALON NR. SEMNATURA
NR. F.O.

1. DATE GENERALE DESPRE PACIENT

NUME ŞI PRENUME (initiale)________

VÂRSTA ______ani SEX _____

DOMICILIUL ______________________________________________________________

STAREA CIVILA: casatorit(a)[ ] necasatorit(a)[ ] divortat(a) [ ] vaduv(a) [ ]

SITUATIA SOCIALA: angajat(a)[ ] casnic(a)[ ]pensionar(a)[ ] somer(a)[ ]altele[ ]

PROFESIA:

 actuala______________________________________________
 anterioara pensionarii___________________________________

2. DATA INTERNĂRII_________________

MOTIVELE INTERNĂRII____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
________

3. DIAGNOSTIC MEDICAL LA
INTERNARE____________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

1
4.ANTECEDENTE HEREDO-COLATERALE
(AHC)______________________________________
___________________________________________________________________________________
________________________________________________________________

5. ANTECEDENTE PERSONALE

Fiziologice (la femei): menarha____________________________________________________

menopauza_________________________________________________
nasteri_____________________________________________________
Patologice: medicale____________________________________________________________

chirurgicale_________________________________________________________

6. CONDIŢII DE VIAŢĂ ŞI DE MUNCĂ

Ocupatie/munca prestata______________________________________________________________

Noxe toxice la locul de munca_________________________________________________________

Alimentatia :
-alimente preferate__________________________________________________________
-lichide ingerate/zi__________________________________________________________
-dieta actuala prescrisa______________________________________________________
Uzul si abuzul de toxice :
-alcool: -produsul preferat__________________________________________________
-cantitatea preferata________________________________________________
-de cand bea alcool_________________________________________________
-tutun: -nr.tigari/zi_______________________________________________________
-de cand fumeaza___________________________________________________
-cafea: _________________________________________________________________
-alte toxice: _______________________________________________________________

Medicamente utilizate in mod curent_____________________________________________________

2
__________________________________________________________________________________
Supra solicitari psihice si fizice______________________________________________________

7. PREZENTAREA BOLNAVULUI IN ZIUA CULEGERII DATELOR( ZIUA

EXAMENULUI)

 Aspectul general____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Constrângeri fizice: sonde [ ]perfuzie [ ]

aparatgipsat [ ] extensie continua [ ]plaga/pansament [ ]

 Tratamentul( in ziuaculegeriidatelor):

-medicamentos_____________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
-chirurgical _______________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________
3
___________________________________________________________________________________

 Alte terapiii interventionale: -litotritie

extracorporeala________________________________

-interventie endoscopica________________________________

-by-pass_____________________________________________

-stenturi coronariene___________________________________

-altele_______________________________________________

___________________________________________________________________________________

 Igieno- dietetic:______________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

8. NEVOI NESATISFĂCUTE- DIAGNOSTICE DE NURSING

4
NEVOI NESATISFĂCUTE DIAGNOSTICE DE NURSING

5
 9. PLANIFICAREA INTERVENŢIILOR AUTONOME ŞI DELEGATE

DATA DIAGNOSTIC DE NURSING OBIECTIVE DATA DIAGNOSTIC DE NURSING OBIECTIVE

6
DATA DIAGNOSTIC DE NURSING INTERVENŢII AUTONOME ŞI DELEGATE EVALUARE