Professional Documents
Culture Documents
NCP BOOKLET
CASE METHOD APPROACH
GUIDE TO PATIENT CARE ANANLYSIS
HEALTH HISTORY
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b.4 Immunizations
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Prescribed
Non – Prescribed
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b.7 Allergies
b.8 Habits
Legend:
S - sister ? - unknown
A. Appetite
C. Dentition _________________________________________________________________________________________________________
A. Bowel _____________________________________________________________________________________________________________
B. Bladder ____________________________________________________________________________________________________________
IV. ACTIVITY – EXERCISE PATTERN
_________ Feeding __________ Toileting ____________ Dressing ___________ Home Maintenance ___________ Shopping
_________ Bathing __________ Bed Mobility __________ Grooming __________ Cooking ______________ General Mobility
B. Oxygenation/ Perfusion
A. Hearing __________________________________________________________________________________________________________
B. Vision ___________________________________________________________________________________________________________
I. GENERAL SURVEY
III. INTEGUMENTARY
C. Nails : _______________________
IV. HEENT
Eyes : Color ( optic disk & conjunctive ) ________ Visual acuity _______ Pupil Response _________ Accomodation _______________
Mouth/ Throat/ Pharynx/ Teeth: ( Color/ Lesions/ Smoothness/ Presence of Cavity ) _________________________________________________
VIII. Cardiovascular
X. Abdomen
NORMAL
A. LABORATORY EXAMINATIONS RESULTS SIGNIFICANCE
VALUES
NORMAL
A. DIAGNOSTIC EXAMINATIONS RESULTS SIGNIFICANCE
FINDINGS
COLLABORATIVE PLAN OF CARE
Medications
Standing Orders
INTERVENTION
PATHOPHYSIOLOGIC NURSING
CUES PLAN/ OBJECTIVE RATIONALE EVALUATION
(Independent/ Dependent/
BASIS DIAGNOSIS
Interdependent)