Part I- Personal System
Part I- Personal System:
Personal data of the patient
Definition of the Self
Self esteem concept
Main complaint
Concept of the self
Growth and development
Body image
Part II- Interpersonal System:
Communication concept
Transaction concept
Role concept
Part III – Social system
Concept of stress (physiological damage)
Authority concept
Status
Organization
Decision making
I. Personal System:
A. Personal data of the patient
Patient Initials___________ Admission Date _________________
Age______
Marital status___________
Gender: ___ (F) ___ (M) Weight: ___________ Height: _________
Address (town) _______________ Nationality__________ Primary Language________ Citizenship ___________
Educational Level_______________ Religion ___________ () Active () Inactive
Information Source: (check with a
X)
_____ Patient ______ Spouse
_____ Child ______ Partner
_____ Parents ______ File
_____ Friend ______ Other Primary Complaint: __________________________________________ __________________________________________ History of Present Illness: ______________ __________________________________________ __________________________________________ Medical Diagnoses: ________________________ __________________________________________
What is your opinion of you as
person? (Definition of Self)
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________ What is your opinion about his condition? __________________________________________ __________________________________________ _____ Demonstrates having full knowledge of the condition. _____Knows part of the condition and its treatment _____Has little or no knowledge of its condition and treatment
What do you understand that you are doing
to improve your condition?
_______________________________
_______________________________
_______________________________ What do you think of the nursing staff in relation to the care they offer you? __________________________________________ __________________________________________ __________________________________________
B. Growth and development
What stage of growth and development according to Erickson is the patient? __________________________________ __________________________________ Explain if the stage of Growth and development is according to the age of the patient? Yes _______no_______ Explain____________________________ ___________________________________ ___________________________________ ___________________________________ Have you had any problem that prevented your physical growth? __________________________________ __________________________________ Do you think you have had a satisfactory personal development? __________________________________ __________________________________ __________________________________ __________________________________
Childhood illnesses
German measles ______
Common measles ______
Diphtheria ______
Chickenpox ______
Smallpox ______
Polio ______
Mumps ______
Rheumatic fever ______
Immunization:
Td ______
Influenza ______
Pneumonia ______
Family history:
Heart disease ______
Pulmonary conditions ______
Cancer ______
Hypertension ______
Tuberculosis ______
Diabetes ______
Others (mention) ______
History of past illnesses
Hypertension Diabetes Respiratory CVA Cardiac Myocardial infarction Sepsis Hepatic Epilepsy Renal failure Dementia Cancer STD Drug addiction Alcoholism Others (specify)
Social History: a. Intake of Alcoholic Beverages () Yes () No Amount ________ Frequency ____________ Type of Beverage_____________ b. Smoking history: 1. Smoke () Yes () No Amount __ Frequency ____ 2. Smoked: () Yes () No How long_____ c. Coffee () Yes () No Quantity ________ Frequency ___________ d. Refreshments () Yes () No Quantity ________ Frequency ___________ Eating Habits: 1. Breakfast () yes () no 2. Lunch () yes () no 3. Dinner () yes () no Orderly diet and route: ______________ ________________________________ ________________________________ Comments : _____________________ ________________________________ ________________________________ History of Domestic Violence or Abuse: ___yes ___No Comments: _____________________ ________________________________
C. Self-esteem
Self Perception: Self concept
Identity ________________________________________________________
Perception of skills ________________________________________
Body Image ________________________________________________
How do you describe yourself or how do you visualize yourself?
How would you describe yourself in front of others? ____________________________________
How do you feel most of the time about yourself? _________________
__________________________________________________________________
Selfconcept
____ You accept physical change as a result of your condition.
____ Is indifferent toward change.
____ Does not accept your physical changes or condition.
____ Do you feel satisfied with what life has given you?
____ Have you achieved your goals in life?
describing yourself or how do you visualize yourself?
How would you describe himself in front of others? ____________________________________
How doyou feel most of the time with yourself?____________________
__________________________________________________________________
Auto – Concept
____ Acepta the physical change as a result of sor condition.
____ Sand is indifferent to change.
____ You do notaccept your physical changes or your condition.
____ Do you feel satisfied with what life has given you?
____ Have you managed to achieve your goals in life?
Special assistive devices _____ Swheelchair _____ Muletas _____ Bastón _____ Andador _____ Prótesis _____ Hearing aids Presence of visual damage Amputación ( ) AK ( ) BK ( ) ESD ( ) ESI Mastectomía ( ) L ( ) R ( ) Radical sutura_________ Edema _______________
II. Interpersonal system
A. Concept of Communication
1. During hospitalization / nursing home How is the relationship with the therapeutic staff? ______________________________________________________________________________________________________________________________________________________________________________________________________
2. How is the communication with roommate / s?
______________________________________________________________________________________________________________________________________________________________________________________________________
Observation: Verbal communication (yes) ____ (no) ____ Non-verbal (gestures) (yes) ____ (no) ____ Cooperative (yes) ____ (no) ____ Isolation (yes) ____ (no) ____ Communicates (yes) ____ (no) ____ Remains quiet (yes) ____ (no) ____ Media present: Television _____________ Computers_________ Phones ______________
B. Concept of Transactions
Family Interaction ____ Positive ____ Negative ____ With your partner ____ With your parents ____ With your siblings ____ Children ____ There is a difference with a member of the immediate family. ____ There are conflicts in the immediate family circle. Acceptance and sense of belonging ____ You receive emotional and physical support from your family. ____ Receives moral support from some family members. ____ You receive spiritual support from your family. ____ You do not receive physical or emotional support from your family.
Participation in Family Activities
_____ Participate in activities:
____ regularly
____ sometimes
_____ Never participates Sexuality _____ Active _____ Maintains sporadic relationships _____ Inactive or performs them every 3 – 4 months
C. Role Concept
What role do you currently play? ________________________________
Who makes up your family nucleus? _____________________________
Of the family problems, which ones worry you the most? _________________
Which is the most difficult for you to handle? ________________________________
How do you handle your problems regularly? _________________________
Who do you turn to when you have a need? ___________________
What people provide support? __________________________________
Social system
Participate in social activities ____ Casino _____ Watch TV ____ Dominoes _____ Listen to the radio ____ Bohemia _____ play cards ____ Internet / social media ____ Other (specify) ________________ Participate in religious observances ____ Visit the church of your choice: ____ Regularly. ____ Every month ____ Occasionally ____ Receives visits from the religious leader and / or parishioners ____ Does not attend any church
Participate in associations or groups of the
community
____ Belongs to a group
Specify _____________________
Position held_______________
____ Only participate if requested
____ Does not belong to any group Sense of belonging within the religious group _____ Receives spiritual and emotional support from the religious leader and parishioners _____ Frequent _____ Occasional _____ Does not receive any support _____ Participates in activities _____ Has a position or task in the church
Available health services you use
____ Instead of residence
____ Medical office
____ Laboratory / Radiology Center
____ Frequency
____ monthly
____ regularity
____ annually
____ when sick
Hospitalizations ____ Frequent ____ About every two to three months ____ Once to twice a year ____ Positive communication with: ____ Family doctor ____ Health professionals
Concept of Stress and behavioral manifestations (Physiological damage)
Respiratory Breathing ________ Pattern value: ___ Regular ___ Irregular ___ Superficial ___ Deep and forced Type of breathing: Eupnea ____ Dyspnea ____ Apnea ____ Tachypnea ____> 20 resp / min Bradypnea ____ <16 resp / min Cough: ___ yes ___ no ___ Productive ___ No Productive Secretions: yes___ no___ Color_________ Consistency ________ Quantity _______________________ Temperature ________ Value ____ afebrile (36- 37.9 °) ____ Hyperthermia (38 ° – 41 ° C.) ____ Hypothermia (<35.9 ° C) ____ Hyperpyrexia (> 41 ° C) Antipyretic treatment : (Name, dose, frequency) _____________________ Skin: Touch: ____ Hot _____ Warm ____ Cold A. Edema: ____ absent ___ present Place: ________________ B. Hematoma / s: ____ Yes (Mark the place) ____ No C. Wound: Location: __________________________ Stitches: ___________ D. Ulcers: (stage) Location: ___________________ Check location:
Circulation
Blood pressure __________ value
____ hypotension <90 / 60mmHg
____ hypertension> 140 / 89mmHg
Pulse: ____________ value
____ strong weak
____regular irregular
Tachycardia ____> 100 beats / min
Bradycardia ____ <60 beats / min
Present in:
____ brachial ____ radial
____ asked ____ Carotid
____ popliteal ____ dorsal foot
____ temporal ____ femoral
Mobility and rest
Exercise
_____ Ambulates independently
_____ Ambulates short distances with assistance
_____ Does not walk:
____ Use of wheelchair
____ Bedridden
_____ Practice physical activities with
regularity (exercises, walking and others)
_____ Practice some physical activities
Times (3-4 times a week).
_____ Does not practice physical activities
Pain
____ pain free
____ soft pain
____ moderate pain
____ severe pain
____ unbearable pain
Analgesic in use: ______________________
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Sleep
_____ Sleeps more than 8 hours a day
_____ Sleep between 5-8 hours
_____ Sleeps less than 5 hours
Night Rituals
_____ Does not perform night rituals
_____ Requires intake of
hot or cold drinks
_____ Requires the intake of
sleep medications.
Medication name:
________________________
_____ Reading
_____ Watch TV, or radio
_____ Others: (Specify) _________
Urinary Elimination
Bowel elimination
Elimination type
____ Spontaneous
____ Retention
____ Incontinence
____ Urostomy
____ Foley catheter # _____
____ Condon foley
Colour
____ Slightly yellow
____ Amber
____ Brown
____ Hematuria
____ Sedimentation
Smell
____ Aromatic
____ Mild to acetone
____ Bacteria
____ Strong acetone odor
____ Bacteria
Urination
____ Without difficulty
____ Oliguria
____ Dysuria
____ Anuria
____ Polyuria
____ Burning
____ Nocturia
____ others
Elimination type
____ Spontaneous
____ Colostomy
____ Ileostomy
Feces
Colour
____ Brown
____ Yellow
____ Gray
____ Black
Smell
____ Normal
____ Fetid
____ Bleeding
Frequency
____ Two to three times a day
____ More than 4 times a day
____ Daily
____ 2-3 times a week.
____ Weekly
____ Less than 1 time per week
Consistency
____ Liquid
____ Liquid with particles
____ Semi-liquid
____ Medium hard
____ Compact
____ Hard
Constipation
____Use of enemas
____Use of suppositories
____Use of laxatives or polishes?
Stool softener ________________
Constant or frequent diarrhea
Smell___________________________
Frequency: _____________________
Quantity: _______________________
Medications used_____________
Reproductive
Feminine
____ Last mammogram _____________
____ Positive ____ Negative
____ Last PAP _____________
____ Last date of menstruation
____ Secretions
____ colour
____ amount
____ smell
____ consistency
____ Edema: Grade _______
____ injuries (specify)
____ ETS (Specify)
Male
Last PSA: ___________
____ secretions
____ colour
____ amount
____ smell
____ consistency
____ Edema
____ Injuries
____ ETS (Specify)
Data Collection Analysis
Personal System
Undisturbed (mark with an X) Altered (mark with X) Comment: Specify how it is altered.
Self esteem concept
Concept of the Self
Growth and development
Body image
Interpersonal system
Communication
Role
Transactions
Social system
Stress:
Breathing
Circulation
Temperature
Skin
Nutrition
Water
Mobility and Rest
Pain
Sleep
Urinary elimination
Bowel elimination
List of problems identified Nursing Diagnoses (NANDA)
1.
2.
3.
Four.
5.
6.
Diagnostic tests:
Name of the Test Description of the Test Patient Value Normal Value Interpretation
Medicines:
Medical order
(Dose, frequency)
Use
Side effects
Contraindications Nursing consideration