Person
( There is a link to a data collection tool at the bottom of the PERSON outline in Module 3 that might help with cueing you on the specific data to gather in each area)
P:
Pertinent Family History:
E:
Pertinent patient and family history:
R:
Status:
S:
Pertinent Patient and Family History:
History
View of self
Perception of stress and ways of coping
Beliefs and attitudes about illness
Family assessment
Home and community
Current Status
Degree of reality orientation - orientation to time, place, and person; memory - remote and recent
General observations of intelligence, behavior, speech, mood or affect, ability to understand and follow
directions, attention span, etc.
P-Need Medications
Labs
Therapeutic interventions
Description of eliminating patterns/methods
Physical assessment of abdomen and urinary system
I&0
Diagnostics
Meds
Labs/diagnostic tests
Therapeutic interventions
Rest
Sleep
Activity
Restrictions on ADL
Physical capabilities/limitations
Pain/comfort
Neuro status
Sensory deficits
ENT
Endocrine system
Diagnostics
Meds
Labs
Therapeutic interventions
Physical environment
Biological (meds, hygiene, immunizations)
Skin assessment/wounds/invasive lines
Temperature Status
Diagnostics
Meds
Labs
Therapeutic interventions (ie: referrals)
O:
Pertinent Patient and Family History:
N:
Pertinent Patient and Family History:
Respiratory history and assessment
Circulatory history and assessment
Diagnostics
Meds
Labs
Therapeutic interventions
History
Abdominal assessment
Physical findings R/T nutritional status:
wt
ht
general appearance
Diet :
Eating/fluid intake patterns: % on the graphic
amount of fluid appropriate for this client:
health of teeth:
Diagnostics
Meds
Labs
Therapeutic interventions
COMPREHENSIVE NURSING DIAGNOSIS LIST (Focus on actuals then risk fors)
Nursing Care Plan
Nursing Diagnosis
Outcome Criteria
Nsg Dx
Interventions
Rationale
Evaluation of
Interventions
1. ASSESS
1.
2.
2.
3.
3.
4. Teach
4.
Support Data
Outcome Attainment
.