Comprehensive Nursing Assessment Tool Client archives I. GENERAL register OF CLIENT Name ML term 65 trip out Female Racial and cultural data: Caucasian Marital status: Widowed devil and ages of children/siblings: 2 adult children, 1 sister, 2 brothers all sustenance lifespan arrangements: Alone Occupation: Retired school teacher learning: College Religious affiliation: Baptist PRESENTING PROBLEM A. line of reasoning in the clients own words of why he or she is hospitalized or seeking help Patient stated she was here because her family extract she was a risk to herself due to her being depressed from the stopping point of her husband earlier in the year. B. Recent difficulties/alterations in ________________________________________________________ 1. Relationships 2. common level of functioning 3. Behavior 4. Perceptions or cognitive abilities C. increase feelings of _____________________________________________________ ____________ 1. Depression 2. Anxiety 3. Hopelessness 4. Being overwhelmed 5. Suspiciousness 6. bewilderment D. corporeal changes, such as _______________________________________________________ 1. Constipation 2. Insomnia 3. Lethargy 4. Weight passage or gain 5.
Palpitations III. applicable HISTORY PERSONAL A. former hospitalizations and illnesses: History of Bipolar, HTN, and DM. Previous hospitalizations for bipolar phrenetic episodes, childbirth, tubal ligation. B. educational background: Masters degree in education C. occupational ba ckground ___________________________________! _______________________ 1. If employed, where? Retired 2. How long at that job? 30 old age 3. Previous positions and reasons for leaving: retired from teaching 4. Special skills ____________________________________________________________________ D. Social patterns 1. attend friends. Patient states she does not have any...If you want to get a full essay, order it on our website: BestEssayCheap.com
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