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fluids_Compatibility_Mode_ - Fluid and Electrolytes Nursing...

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Fluid and Electrolytes
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Nursing Health History
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Biographic Data 1. Name 2. Address 3. Age 4. Sex 5. Race 6. Marital status 7. Occupation 8. Religious orientation 9. Health care financing
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Chief Complaint What brought you to the clinic or hospital? What is troubling you? Told in the client’s own words , the chief complaint establishes the purpose of the contact, provides direction for the assessment, and establishes the nurse-client relationship
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Gather information to fully describe the client’s problem. Ask questions that help the client describe the specific signs and symptoms associated with the problem and provide a history to the present illness
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History of Present Illness What is the chronological sequence of events in reference to the client’s chief complaint? a. When did the symptoms start? b. How often ? c. Type of activity of client when problem occurred? Was help or consultation sought? What were the medications used? How has the problem interfered with daily life?
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Past History Childhood diseases Immunizations Allergies Accidents and injuries Hospitalizations Medications
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siblings, children, or ages of death and causes Hypothermia Infant Feeding Pattern, Ineffective Nausea Nutrition, Imbalanced, Less Than Body Requirements Nutrition, Imbalanced, More Than Body Requirements,
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Functional Health Patterns* 1. Health Perception and Health Management Pattern a. How has the general health been? *Adapted from Marjorie Gordon's Functional Health Patterns b. Any colds in the past? c. Most important things done to keep healthy? Do you think these things make a difference to health?
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Functional Health Patterns d. Do you use tobacco? In what form? Have you ever used tobacco in the past? When and for how long? e. Use of alcohol or drugs? f. Do you do breast self-examination? g. In the past, has it been easy to find ways to follow things nurses/ doctors suggest?
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Functional Health Patterns h. If appropriate - what do you think caused the illness? Actions taken when symptoms were perceived? Results of action? i. If appropriate – things important to you while you are here in the hospital/ clinic? How can we be most helpful? j. Traditional concepts of health and illness? Beliefs and practices?
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Energy Field, Disturbed Health Maintenance, Ineffective Health-Seeking Behaviors (Specify) Infection, Risk for Injury, Risk for Risk for injury, Suffocation Risk for injury, Poisoning Risk for injury, Trauma
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Latex Allergy Response, Risk for and Actual Management of Therapeutic Regimen, Effective Management of Therapeutic Regimen (Individual, Family, Community), Ineffective Management of Therapeutic Regimen, Readiness for Enhanced
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Noncompliance (Specify) Perioperative-Positioning Injury, Risk for Protection, Ineffective Surgical Recovery, Delayed
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Functional Health Patterns 2. Nutritional and Metabolic Pattern a. Typical daily food intake? Describe.
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