Angeles College Establishment

Angeles College Establishment

Angeles City

NCM 102 – Organization Contextual investigation ( Pedia )

I. Presentation

A. Ebb and flow patterns about the Illness condition

B. Purposes behind picking such case for presentation

II. NURSING Evaluation

1. Individual Information

(name, age, sex, religion, name of folks, location, date of conception, spot of conception, nationality, date of confirmation and release)

NOTE: show witness and state relationship to customer

2. Apropos FAMILY HISTORY ( up to third degree relationship including dates)

a. size of gang

b. mother’s past pregnancies in sequential request and her dispositions towards them, method of conveyances

c. living condition including lodging and financial status

d. social variables influencing the family’s strength (superstitious convictions, wellbeing states of mind)

3. Individual HISTORY

a. Pre-natal – mother’s practices/propensity amid pregnancy

b. Conception span and circumstances of work, home or clinic

c. C nourishing

d. Development and improvement (customer focused; from earliest stages to present age)

– notice month or year when particular improvement was accomplished

– conduct on reference to the diverse hypotheses of development and advancement

– Erick Erikson – Sigmund Freud

– Jean Piaget

e. Vaccination status

4. HISTORY OF PAST Disease

5. HISTORY OF PRESENT Disease

6. PHYSICAL EXAMINATION (IPPA Cephalocaudal Approach)

– Note: Introductory appraisal upon confirmation and on each NPI, particular date ought to likewise be incorporated

7. Analytic AND Research facility Techniques

Analytic/

Research center

Strategies

DATE Requested

DATE RESULT(S)

INDICATION(S)

PURPOSE(S)

RESULTS( First, Second, Third )

Typical Qualities

(UNIT Utilized As a part of THE Clinic)

Examination AND Translation OF RESULTS

(patient-based)

Note : Nursing obligations before, amid and after the system ought to likewise be incorporated

III. Life structures AND PHYSIOLOGY (with visual guides)

IV. THE PATIENT Sickness

A. Schematic Chart

1. Book Focused

2. Patient-focused

B. Amalgamation of the ailment

1. meaning of the sickness

2. Inclining/encouraging elements

3. sign and indications

4. wellbeing advancement and preventive parts of the ailment

V. THE PATIENT AND HIS Consideration

A. Therapeutic Administration

a. IVFs, BT, NGT nourishing, Nebulization, TPN, Oxygen treatment, And so on.

Therapeutic administration/treatment

Date requested

Date performed

Date changes/d/c

General Depiction

Indications(s)

On the other hand

Reason (s)

(patient-focused)

Customers reaction to treatment

NOTE: Nursing obligations preceding. Amid and after the treatment ought to additionally be incorporated

b. DRUGS

Name of drug(s) non specific and brand name

Date requested

Date Given/taken

Date changes/d/c

Course of organization

Measurements and recurrence of administrator

General activity ,

Characterization

System of activity

Indications(s)

Then again

Reason (s)

(patient-focused)

Customers reaction to prescription

With genuine symptoms

NOTE: Nursing obligations preceding. Amid and after the treatment ought to additionally be incorporated

c. DIET

Kind of Eating routine

Date requested

Date performed

Date changes/d/c

General Depiction

Indications(s)

Then again

Reason (s)

(patient-focused)

Customers reaction and/or response to count calories

NOTE: Nursing obligations preceding. Amid and after the treatment ought to additionally be incorporated

d. Movement and Activity

Kind of Activity

Date requested

Date began

Date changes/d/c

General Depiction

Indications(s)

Then again

Reason (s)

(patient-focused)

Customers reaction and/or response to movement/exercise

NOTE: Nursing obligations before. Amid and after the treatment ought to additionally be incorporated

B. SURGICAL Administration ( Booked-Based if not yet performed

/Patiend based – if performed)

a. Brief portrayal

b. Nursing obligations before, amid and after the operation

C. NURSING Administration (atleast five issues)

1. Nursing Consideration Arrangement

Appraisal

Nursing Conclusion

Exploratory Clarification

Arranging

(objective/objective)

Mediation

Justification

Assessment

2. Real Sopiers

VI. CLIENT’S Every day PROGRESS IN THE Healing center

1. Customer’s every day advancement outline (from admission to release)

DAYS

Confirmation

2

3

4

5

Release

Nursing Issues

1. Altered…..

2. hazard for …

Indispensable signs

PR,RR,BP,PP, TEMP

(Incorporate real results)

Lab method

(Incorporate real results)

DRUGS

DIET

Action/Exercise

2. Release Arranging

a. General state of customer upon release

b. System

VII. CONCLUSION and Suggestion ( Learning Inferred)

VII. List of sources