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PA Tool (Revised 2019) 111
PA Tool (Revised 2019) 111
NURSING ASSESSMENT I
PATIENT’S PROFILE
HABITS
1. Tobacco
2. Alcohol
3. OTC-drugs/ non-prescription drugs
A. CHIEF COMPLAINTS:
B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)
1. Present Illness
2. Hospital Environment
E. SUMMARY OF INTERACTION
Physical Examination
GENERAL
HEENT
INTEGUMENTARY
RESPIRATORY
CARDIOVASCULAR
DIGESTIVE
EXCRETORY
MUSCULOSKELETAL
NERVOUS
ENDOCRINE
DRUG STUDY
BRAND NAME GENERIC Prescribed and Mechanism
NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
NURSING ASSESSMENT II
DAY 1 DAY 2
1.ACTIVITIES- REST
a. Activities
b. Rest
c. Sleeping pattern
2.NUTRITIONAL- METABOLIC
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplement
food
3. ELIMINATION
4. EGO INTEGRITY
a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
5. NEURO-SENSORY
a. Mental state .
touch)
6. OXYGENATION
a. Vital signs
Temperature
Respiratory rate
Heart rate
Blood pressure
b. Lung sounds
c. History of Respiratory
Problems
7. PAIN-COMFORT
b. Comfort
measures/Alleviation
c. Medications
8. HYGIENE AND ACTIVITIES
OF DAILY LIVING
9. SEXUALITY
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
SUMMARY OF MEDICATION
CARDIOVASCULAR SYSTEM
Functions of the cardiovascular system
Blood circulates through a network of vessels throughout the body to provide individual cells with oxygen and nutrients and helps dispose of metabolic wastes.
The heart pumps the blood around the blood vessels.
Blood vessels
ARTERIES
carry oxygenated blood away from the heart. They are thick hollow tubes which are highly ELASTIC which allows them to DILATE (widen) and constrict
(narrow) as blood is forced down them by the heart. Arteries branch and re-branch, becoming smaller until they become small ARTERIOLES which are
even more elastic. Arterioles feed oxygenated blood to the capillaries. The AORTA is the largest artery in the body, taking blood from the heart,
branching into other arteries that send oxygenated blood to the rest of the body.
CAPILLARIES
distribute the nutrients and oxygen to the body's tissues and remove deoxygenated blood and waste. They are extremely thin, the walls are only one
cell thick and connect the arterioles with the venules (very small veins).
VENULES
(very small veins) merge into VEINS which carry blood back to the heart. The vein walls are similar to arteries but thinner and less elastic. Veins carry
deoxygenated blood towards the lungs where oxygen is received via the pulmonary capillaries. The PULMONARY Veins then carries this oxygenated
blood back to the heart.
The Heart
The heart is a hollow muscular organ which beats over 100,000 times a day to pump blood around the body's 60,000 miles of blood vessels. The right side of
the heart receives blood and sends it to the lungs to be oxygenated, while the left side receives oxygenated blood from the lungs and sends it out to the tissues
of the body.
The heart has FOUR CHAMBERS, in the lower heart the right and left Ventricles, and in the upper heart the right and left Atria. In a normal heart beat the
atria contract while the ventricles relax, then the ventricles contract while the atria relax. There are VALVES through which blood passes between ventricle
and atrium, these close in such a way that blood does not backwash during the pauses between ventricular contractions. The right and left ventricles are divided
by a thick wall (the VENTRICULAR SEPTUM), babies born with "hole in the heart" have a small gap here, which is a problem since oxygenated and
deoxygenated can blood mix. The walls of the left ventricle are thicker as it has to pump blood to all the tissues, compared to the right ventricle which only
pumps blood as far as the lungs.
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
DISCHARGE PLAN
CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )
1. MEDICATIONS
2. EXERCISE
3. DIET
4. HEALTH TEACHING