DOSARUL 

DE ÎNGRIJIRE - NURSING

DATE PERSONALE

Numele _________________________Prenumele _______________________

Vârsta _______________Sexul ______________________________________

Membrii familiei __________________________________________________

Locul de muncă ___________________________________________________

Domiciliul _______________________________________________________

Condiţiile de trai___________________________________________________

Situaţia familiară __________________________ Telefonul ________________

DATE DESPRE SPITALIZARE

Data internării: ziua __________ luna _________ anul__________ora_________

Denumirea secţiei __________________________________________________

Data externării ____________________________________________________

DIAGNOSTICUL MEDICAL

_______________________________________________________________

_______________________________________________________________

DIAGNOSTICUL DE NURSING

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________
ECHIPA DE ÎNGRIJIRE

Medic_______________________Asistenta medicală_____________________

infermiera_______________________________________________________
 CULEGERA DATELOR

A) DATE SUBIECTIVE
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________________________________________________
_______________________________________________________________
_____________________________________________________________

B) DATE OBIECTIVE
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
___________________________________________________
 PLANUL DE ÎNGRIJIRE - NURSING

Nevoia Diagnostic de Nursing
Funcţiile vitale Îngrijiri realizate
Evaluarea
fundamentală Obiectivul Evalua
Data R ProblemePS T
Etiologie TA
Semne (S) Eliminări Igiena
perturbată de sănătate îngrijirilor Autonome Delegate periodică
perio
(E) manifestări personală
(P)

FIŞA DE EVALUARE - MONITORIZAREA ZILNICĂ
EVALUAREA FINALĂ A PACIENTULUI EXTERNAT
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

RECOMANDĂRI LA EXTERNARE
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Semnătura as.med ___________________________________________