Use of street drugs or alcohol:NA ME USED (^) AMOUNT OFTEN LAST EFFECTS a. Respirations: Normal Rate d. Neurological status: b. Skin: Warm Skeletal deformities (describe) Cool Pain (describe) Cyanotic Tremor s (^) Other 3. Pertinent physical assessments:c. Musculoskeletal status: Weakness Needle tracks Headaches (describe location and frequency) Evidence of: Rash Seizures (describe method of control) History of (check all that apply): Coordination (describe limitations) Degree of range of motion (describe limitations) Poor turgor HOW W HENUSED USED PRODUCED Clammy Rhythm Hirsutism Dry Bruising Labored Loss of hair Edematous Moist Pink
Hypertension Phlebitis swallowing? Food allergies: (^) f. Gastrointestinal: (^) Varicose veins Fainting spells e. Cardiovascular: B/P Numbness/tingling in extremities Any problems with chewing or Shortness of breath Any recent change in weight? Heart murmur Tingling/numbness (describe location) Dentures? Upper History of (check all that apply): Usual diet pattern: Ankle/leg edema Lower Palpitations Chest pain Pain in legs Dizziness Pulse
Nursing Process: One Step to Professionalism ●^11
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