Richard J. Daley College
Nursing 101 Data Collection for Care Plan
Section I – Demographic Data:
Patient Initials: K. J. Sex: Female MSWD: Married
Age: 44 No. of children: 1 Occupation: Disabled
Section II- Admission Data
1. Date admitted: 10/19/2007
2. Admitting diagnosis: Hematomesis, melanotic stools, cirrhosis, hepatorenal syndrome.
3. Allegries: Codiene
4. Signs and symptoms on admission: jaundice appearance, lethargic, oriented x 1, vomiting bright red blood, has had black stools.
5. Summary of History and Physical on admission: Patient has a history of hepatitis C, alcohol abuse, cirrhosis, GI bleed, pancreatitis. Patient was lethargic, with mental status changes. Patients appearance is jaundice, stomach distended and tender to palpation.
6. History of Surgical Procedures with dates: Not Known
Section III-Progress Report of Patient:
Patient was brought to Mercy Hospital ER by her husband who found patient lying naked on the doorway. She has......
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