LICEUL TEORETIC “GEORGE EMIL PALADE”

SCOALA POSTLICEALA SANITARA

PREZENTARE DE CAZ CLINIC

MODULUL: …………………………………………………….
SPITALUL:
SECTIA:
SALON NR.:
ELEV PRACTICANT:

1. DATE GENERALE DESPRE PACIENT

NUME SI PRENUME (initiale) ________

VARSTA ______ 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 INTERNARII _________________

MOTIVELE INTERNARII____________________________________________________________
___________________________________________________________________________________

3. DIAGNOSTIC MEDICAL LA INTERNARE__________________________________________

4. ANTECEDENTE HEREDO-COLATERALE (AHC)___________________________________

___________________________________________________________________________________
___________________________________________________________________________________

5. ANTECEDENTE PERSONALE (AP)

Fiziologice (la femei): menarha____________________________________________________

menopauza_________________________________________________
nasteri_____________________________________________________
Patologice: medicale____________________________________________________________
chirurgicale _________________________________________________________
LICEUL TEORETIC “GEORGE EMIL PALADE”
SCOALA POSTLICEALA SANITARA

6. CONDITII DE VIATA SI DE MUNCA

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 _________ de cand bea ___________
-tutun: -nr.tigari/zi ___________________ -de cand fumeaza________________
-cafea: ____________________ alte toxice: __________________
Medicamente utilizate in mod curent_____________________________________________________
__________________________________________________________________________________
Suprasolicitari psihice si fizice _________________________________________________________

7. PREZENTAREA BOLNAVULUI IN ZIUA CULEGERII DATELOR

Aspectul general_____________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Constrangeri fizice: sonde [ ] perfuzie [ ] aparat gipsat [ ] extensie continua [ ] plaga/pansament [ ]

Tratamentul ( in ziua culegerii datelor):
-medicamentos_____________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
-chirurgical _______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
LICEUL TEORETIC “GEORGE EMIL PALADE”
SCOALA POSTLICEALA SANITARA

Alte terapii interventionale: -litotritie extracorporeala________________________________________

-interventie endoscopica________________________________
-by-pass_____________________________________________
-stenturi coronariene___________________________________
-altele_______________________________________________
Igieno- dietetic:______________________________________________________________________
___________________________________________________________________________________

8. NEVOI NESATISFACUTE- DIAGNOSTICE DE NURSING

LICEUL TEORETIC “GEORGE EMIL PALADE”
SCOALA POSTLICEALA SANITARA

9. PLANIFICAREA INTERVENTIILOR AUTONOME SI DELEGATE

DATA DIAGNOSTIC DE NURSING OBIECTIVE DATA DIAGNOSTIC DE NURSING OBIECTIVE

DATA DIAGNOSTIC DE NURSING ACTIUNI EVALUARE

LICEUL TEORETIC “GEORGE EMIL PALADE”
SCOALA POSTLICEALA SANITARA