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NCP วริศรา สระแก้ว25B Othoช2
NCP วริศรา สระแก้ว25B Othoช2
NCP วริศรา สระแก้ว25B Othoช2
วิทยาลัยพยาบาลบรมราชชนนี สรรพสิทธิประสงค์
รายงานการวางแผนการพยาบาล (Nursing Care Plan)
วิชา ปฏิบัติการพยาบาลผู้ใหญ่ ๑
นางสารว ศ ? สระแ
ชื่อ-สกุล นักศึกษา.............................................เลขที ่..........ชั้นปี..........รุ่น...........หลั
25 2 5 กสูตร พยาบาลศาสตรบัณฑิต
4 มภา
วันที่.............................................หอผู
I6 '% ·อโฮป
้ป่วย................................................................เตียง..............................................
ต ⑥
ประวัติส่วนตัว
ผู้รับบริการเพศ....................................................อายุ
ชาย โส
...........ปี สถานภาพสมรส..........................................................
2.
ไทย
เชื้อชาติ...........ศาสนา...............ระดั
พ ก ัลงศึกษา ดมศึ
บการศึกษา..............................อาชี
ก ก
พ.......................รายได้ ........................บาท/เดือน
-
ที่อยู่ปัจจุบนั อาเภอ........................................จังหวัด..........................................................................................................
⑤
มภา
รับไว้ในโรงพยาบาลวันที่.....................................เดือน.....................................พ.ศ..................เวลา...................................
2567 15. 40 ป
4
มภา
รับไว้ในความดูแลของนักศึกษาวันที่......................เดือน.....................................พ.ศ..................เวลา................................
2567 16.30 น
ประวัติครอบครัว
สถานภาพในครอบครัว ( ) หัวหน้าครอบครัว ( ) สมาชิก :
บุคคลในความรับผิดชอบ.................คน -
า นไม ้ น ี ยว ใ
สภาพแวดล้อม.......................................................................................................................................................................
เด
สุขภาพอนามัย.......................................................................................................................................................................
ประวัติการเจ็บป่วย
แขนขวายก ไม่ ้น Motor power grade -6 เเ ออน อนมาโรงพยาบาล มาตามนัดเพอ า ด Nerv
อาการสาคัญ.........................................................................................................................................................................
.1
ประวัติการเจ็บป่วยปัจจุบัน
6 เ อ น ่อนมา ขับ M2 จ้ม ไม่สลบ จ เเหต ุการ ์ไ ไ Nofr
่ actur eเ บ เวณแข นข
ว วาเปป กษา ว ่โรงพยาบา าล ม.อ
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ง Refer าโรงพยาบาลสรรพ ท ประสง ตรวจ Electromyograp
phy ( EM. G ) พบเ นปประสาทบาดเ บ Motor power grade ปวดเป็
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rม
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ประวัติการเจ็บป่วยในอดีต
อ 1 · ังกแแ วเเคย าต ด
-เ...................................................................................................................................................................................................
ป
การตรวจร่างกายตามระบบ
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สรุปผลการตรวจทางห้องปฏิบตั ิการตั้งแต่แรกรับจนถึงปัจจุบนั
สรุปปัญหาจากผลการตรวจทางห้องปฏิบัตกิ าร
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อ้างอิง ...................................................................................................................................................................................
ยาที่ผู้ป่วยได้รับ
ยา สารน้าทางหลอดเลือดดา และ ระบุกลุ่มยา กลไกการออกฤทธิ์ ผลข้างเคียง เหตุผลในการใช้ยา
อาหารทางหลอดเลือดดา คุณสมบัติ ในผู้ป่วยรายนี้
(ขนาด ทางที่ให้ เวลา) และวันที่ที่
ได้รบั
1.
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อ้างอิง.................................................................................................................................................................
วันที่ 1 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg
วันที่ 2 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg.
วันที่ 3 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg
การวางแผนการพยาบาล (วันที่.................................................)
ข้อวินิจฉัยการพยาบาล กลไกการเกิดปัญหา วัตถุประสงค์และ กิจกรรมการพยาบาล เหตุผลกิจกรรมการ ประเมินผลการพยาบาล
และข้อมูลสนับสนุน เกณฑ์การประเมิน พยาบาล
อ้างอิง ......................................................................................................................................................................................................................................................
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การวางแผนการพยาบาลในช่วงวันที่ศึกษา (เรียงลาดับตามวันที่ที่ดูแล)
วันที่.........................................
ข้อวินิจฉัยการพยาบาล กลไกการเกิดปัญหา วัตถุประสงค์และ กิจกรรมการพยาบาล เหตุผลกิจกรรมการ ประเมินผลการพยาบาล
และข้อมูลสนับสนุน เกณฑ์การประเมิน พยาบาล
สรุปผลการดูแลและการเปลี่ยนแปลงของผู้ป่วย
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การวินิจฉัยครั้งสุดท้าย (ก่อนจาหน่าย)
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คาแนะนาที่จาเป็นหรือแผนการจาหน่ายสาหรับผู้ป่วยรายนี้
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................................................................................................................................................................. อ้างอิง
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