Revista de Enfermeria Psiquiatrica

Descargar como docx, pdf o txt
Descargar como docx, pdf o txt
Está en la página 1de 4

REPÚBLICA BOLIVARIANA DE VENEZUELA

UNIVERSIDAD NACIONAL EXPERIMENTAL


POLITÉCNICA DE LA FUERZA ARMADA NACIONAL BOLIVARIANA
UNEFA
NÚCLEO CARABOBO – EXTENSIÓN BEJUMA

REVISTA DE ENFERMERIA PSIQUIATRICA


1. DATOS DEMOGRAFICOS:
NOMBRE Y APELLIDO DEL USUARIO:___________EDAD:______SEXO:____PROFESION:__________
DIRECCION:________________________________________NACIONALIDAD:__________________
NIVEL EDUCATIVO:_____________________________UNIDAD:_____________________________
FECHA DE INGRESO: ________________________________

2. MOTIVO DE INGRESO:
A._______________________________________________________________________________
B.________________________________________________________________________________
C.________________________________________________________________________________

3. HISTORIA DE LA ENFERMEDAD ACTUAL:


_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

4. DIAGNOSTICO MEDICO:
A._______________________________________________________________________________
B.________________________________________________________________________________
C.________________________________________________________________________________

5. DATOS SUBJETIVOS: VALORACION DE LOS PATRONES FUNCIONALES (PATRONES ALTERADOS)


A._______________________________________________________________________________
_________________________________________________________________________________
B.________________________________________________________________________________
_________________________________________________________________________________
C.________________________________________________________________________________
_________________________________________________________________________________

6. PARACLINICOS
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
7. DATOS OBJETIVOS (ENTORNO AL PACIENTE)

 EXAMEN FISICO GENERAL:


_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

 EXAMEN NEUROLOGICO:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

 EXAMEN MENTAL:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
8. DIAGNOSTICOS DE ENFERMERIA
 _________________________________________________________________________________
_________________________________________________________________________________
 _________________________________________________________________________________
_________________________________________________________________________________
 _________________________________________________________________________________
_________________________________________________________________________________

9. ACTIVIDADES PENDIENTES
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

10. CONCLUSIONES Y RECOMENDACIONES:


_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

NOMBRE DEL ESTUDIANTE: ___________________________________


FECHA:____________________________
NOMBRE Y APELLIDO:__________________EDAD:______SEXO:______FECHA:______________
HORA:________ SERVICIO:__________________ SALA:_______ CAMA:_______
Dx MEDICO:______________________________________________________________________

Evaluación de enfermería
S.O.A.P.I.E.
S:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

O:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

A:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

P/I:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________

E:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

También podría gustarte