Normal Spontaneous Delivery
ASSESSMENT: NURSING JOBS HEALTH BACKGROUND
COLLECTING AND CLUSTERING SUBJECTIVE DATA (Initial Interview – Comprehensive) DEPENDING ON GORDON'S FUNCTIONALHEALTH PATTERNS
My spouse and i. BIOGRAPHIC DATA
___ Age: _______ Sex: ___________
Marital Position: ___________ Occupation: _________________________ Religious Orientation: ________________ Health care funding and typical source of medical care: ____________________________________________________
2. CHIEF ISSUE OR REASON FOR VISIT
What brought you to the medical center or clinic?
What is unpleasant you?
3. HISTORY OF PRESENT ILLNESS
Question what was the chronological sequence of events in reference to the client's main complaint. When ever symptoms began? ________________________________________ When? _____________________________________________________ Kind of activity of client when issue occurred, etc . ________________________________________________ Was help/consultation wanted? ____________________________________________________________
Medication employed? ____________________________________________________________
Ask how difficulty has interfered with working day life. If perhaps pain:
1 ) C-haracter
2 . O-nset
7. A-ssociated elements
IV. PAST HISTORY
A. Childhood illnesses ___________________________
M. Immunizations ________________________________
C. Allergic reactions (Food, Medicines) _______________________________ G. Accidents and injuries ____________________________________ E. Hospitalizations (When? How come? )____________________________ Farreneheit. Medication _______________________________________________
V. FAMILY HISTORY AND ANCESTORS OF CONDITION
A. Health and ages of patients, brothers and sisters, children, or ages at death to result in B. Disease in the family members similar to the patient's
C. Familial occurrence of hypertension, tuberculosis, diabetes, seizures, mental illness; others especially since suggested by simply PI.
MIRE. FUNCTIONAL OVERALL HEALTH PATTERN
A. Health Perception and Overall health Management Pattern
1 . How has the general health been?
2 . Any the common cold in the past?
three or more. Most important things done to retain health? You believe these things really make a difference to wellness? (Include friends and family folk/remedies in the event appropriate) 5. Use of smoking cigarettes, alcohol, medicines? Breast exam?
5. In past times, has it recently been easy to find approaches to follow points nurses/doctors recommend? 6. In the event that appropriate: so what do you think caused the illness? Activities taken when ever symptoms had been perceived? Outcomes of action? 7. In the event appropriate: issues important to you while you are within the hospital medical center? How can we be most helpful? 8. Traditional ideas of into the illness? Values and techniques?
B. Healthy and Metabolic Pattern
1 ) Typical daily food intake? Illustrate. Supplements?
2 . Typical daily smooth intake? Illustrate.
3. Pounds loss/gain? Sum?
5. Meals or consuming discomforts? Diet restrictions?
6. Heal very well or terribly?
7. Epidermis problems? Lesions? Dryness?
almost eight. Dental problems?
1 . Intestinal elimination pattern. Describe. Rate of recurrence? Characteristics? Soreness? 2 . Urinary elimination design. Describe. Regularity? Discomfort? Problem in control? several. Excess Perspiration? Odor complications?
D. Activity-exercise Pattern
1 ) Sufficient energy for doing desired necessary activities? 2 . Exercise routine? Type? Steadiness?
3. Free time: leisure actions? Child: enjoy activities?
four. Perceived capability for (code level)