STUDIU DE CAZ – ___________________(denumire patologie)

1. INFORMAŢII GENERALE
NUME: _____________
PRENUME: _____________
SEX: ___________
VARSTA: ___de ani
GREUTATE: ___kg
INĂLȚIME: ___ m
NATIONALIATEA: __________
STAREA CIVILĂ: __________
ADRESA: __________
OCUPAŢIA: __________

DATA INTERNĂRII: __________

ORA INTERNARII: __________
MOTIVELE INTERNARII: ____________________________________________________________________________
ISTORICUL BOLII
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
ANTECEDENTE PERSONALE: __________
ANTECEDENTE HEREDOCOLATERALE: __________
CONDITII DE VIATA SI MUNCA: __________
COMPORTAMENTE: __________
ALERGII: __________

EXAMEN CLINIC GENERAL

STARE GENERALĂ: ___________________________________________________________________________________________________________
STARE DE CONŞTIINŢĂ: ______________________________________________________________________________________________________
FACIES: _____________________________________________________________________________________________________________________
TEGUMENTE: _______________________________________________________________________________________________________________
MUCOASE: __________________________________________________________________________________________________________________
ŢESUT CONJUCTIV ADIPOS: __________________________________________________________________________________________________
SISTEM GANGLIONAR: _______________________________________________________________________________________________________
SISTEM MUSCULAR: _________________________________________________________________________________________________________
SISTEM OSTEROARTICULAR: _________________________________________________________________________________________________
SISTEM RESPIRATOR: _____________________________________________________________________________, FR = __________respiratii/min.
 APARAT CARDIOVASCULAR: TA=__________mmHg, AV = __________pulsaţii/minut, __________, SaO2 = __________%;
APARAT DIGESTIV: ________________________________________________________________________________________________________
APARAT UROGENITAL: ____________________________________________________________________________________________________
SISTEM NERVOS: __________________________________________________________________________________________________________

Nevoie afectate: se vor ordona dupa importanta!

1. Nevoia de a evita pericolele;
2. Nevoia de a-si mentine temperatura in limite normale;
3. Nevoia de a-si mentine tegumentele curate si integre;
4. Nevoia de a se alimenta si hidrata
5. Nevoia de a se odihni;
6. Nevoia a respira si a avea o buna circulatie;
7. Nevoia de a se misca si a avea o buna postura
8. Nevoia de a se recrea;
9. Nevoia de a se realiza
10. Nevoia de a se imbraca si dezbraca;
11. Nevoia de a comunica;
12. Nevoia de a elimina;
13. Nevoia de a invata cum sa-si pastreze sanatatea;
14. Nevoia de a actiona dupa credintele si valorile sale.
 Interventii

Nevoia afectata Diagnostic de ingrijire (PES) Obiective Autonome Delegate Evaluare