Foundations Clinical Prep Form (CPF) – Long Term Care Student Name:Clinical Instructor: Pt. Age:M – FAllergies & reaction:NKA Reason for moving to this facility (Story of how/why client was admitted): Previous Medical History (PMHx): AsthmaEmphysemaArthritisCancerHepatitisDiabetesGlaucomaDiverticulitis UlcerOsteoporosisSeizureCHFKidney DzStroke/TIAAnginaCAD MIPalpitationHTNDementiaOther: Previous Surgical History (PSHx): Year:Surgery:Year:Surgery: Pain Hx: Pain N – YChronic or AcuteLevel 012345678910Acceptable 0123456789 P– Provocation: P– Palliation: Q– Quality: Q– Quantity: R– Region: R– Radiation: S– Severity: T– Timing: U– Understanding (client): Pharm & Non-pharm pain therapies: Problem statement:PROBLEMr/tETIOLOGYaebSIGNS/SYMPTOMS (EVIDENCE) Nutrition Hx: SUBJECTIVE:OBJECTIVE: N/AHeight:Weight:BMI: Nausea/Vomiting:Diet:NPO – hrs/days:PO - Type: Heartburn:% meal eaten:Breakfast:Lunch:Dinner: Appetite:Self Feed: N – YFeed with assistance: N – Y GoodFairGT/NG feed:N/AIntermittentContinuous-rate: PoorRecent Weight Change: N – Y 1 Rev. 01/2020
Problem statement:PROBLEMr/tETIOLOGYaebSIGNS/SYMPTOMS (EVIDENCE) Rest/Sleep Hx: Bedtime:#hrs:RestedUnrestedDreams N - Y Naps: N - YProblems falling asleep: N – YWhat helps with sleep: Problem statement:PROBLEMr/tETIOLOGYaebSIGNS/SYMPTOMS (EVIDENCE) Family/Support Hx: Living Situation:
Want to read all 6 pages?
Previewing 3 of 6 pages Upload your study docs or become a member.
Want to read all 6 pages?
Previewing 3 of 6 pages Upload your study docs or become a member.
End of preview
Want to read all 6 pages? Upload your study docs or become a member.
