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EXAMINAREA PACIENTULUI TEMATIC CU STABILIREA DIAGNOSTICULUI DE NURSING

1. N.P. pacientului_____scrieți familia voastră Vârsta__________Sexul__________


2. Data internării______________locul de muncă________________profesia________________
3. Domiciliul_____________________________________polița de asigurare_________________
4. Diagnosticul la internare_________________________________________________________
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5. Acuzele:_______________________________________________________________________
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6. Anamneza bolii:_________________________________________________________________
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7. Anamneza vieții:________________________________________________________________
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8. Datele obiective:________________________________________________________________
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9. Statusul local:___________________________________________________________________
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10. Diagnosticul medical:____________________________________________________________
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11. Stabilirea diagnosticului de nursing:
Nevoia Problema de Etiologie Manifestările Obiectivul Intervențiile
fundamentală sănătate de specifice
perturbată dependență
examinarea
bolnavului

determinarea
evaluarea
problemei

realizarea planificarea
obiectivelor măsurilor

DIAGNOSTICUL DE NURSING

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