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Roy Adaptation Model - Physiological Mode
PHYSIOLOGICAL MODES
Story Hand grips rot
Fou
| Elimination (Urinary and}
Bowel Elimination)
|- bad ON. 5It, motu
fart, be, Soll choot,
no dlicuchea , no block
_ Soft, fat atel.,non-
|dutended, non fenceeness
ua
Ne tedster |
|- No Vi
[ wapeftl ree en all enn
pebeuibis ‘ables aca Md OE
sue leary (rotection) acy Res
= ric on Ram — | 000 whmedkerte aid
dl tp lab cawing eed) At ROM, shenth
~ Frisk of ect Joni in y-S]bectoenthys
we Halltng Elquis « AA
- brad screed) a
ul awsist,
ep {obes of toh lunge
sunbed leocursce
Ibe kL bower
he
Shin color appropricrte. |
goit,, ambulatirg
+
(Endocrine)
= Blood qhccie 231
adwit., 17 1@ 000
~ he of DM pe I
- Accucheck ac ¢ ho
| Pain (Neurological) Pertusion (Gas Trans a
{ a Tansport) | Oxygenation (Gas exchon ite 1
idk foc’ |pSG TREE say Ale Bu] Era ate |
[oa Gramsoran P17) — eR 05, chat qpantion 4
redicing Pavan) tae by aor lla ge i ‘No jlue reaction |
Me Ste Sainrauler ehythen , i + aveehti
es arr oath 5, Nb coughing, no spin, | i eaity. re |
- 7 ea oe Ecler 2 on ankles — Np sy if ase : 7
AO x4 bxlatfca We | ON 259
pave alt F wet tes sheng rb nae io No diffalt slg
Gar speech q 7 Ms 40 ifr) |
» eehere d Haft poss Fe ae neds clr 3. a Os)
Upperdanhure, aff lower
tecth intact
bite na
Glucose Regulation
+e palpation Fath weight) bearing ft Inoilin zhdieg see
parton BS iw [te cf Sage, wiouen) ver ph sete Vereen + actbe
all quactants oy inta Phar ke ULF rH lab oceed
| Contant o| Hadelerg be pots AH AIC pawmaap No 19F a
leew : fon 4127 @ #¢ moral
L NS cbieulty vol sen sept an Ap More
IV/LINES?/ DRAINS:
ff
DRESSINGS / DRAINS:
foam cag an fhe coccyx for presmure alleer penphida
VITAL SIGNS TRENDS: (pertinent)
Date/Time hina ° F rae ]o2saT TGtucose—]
oe l
ald
nq 4
a
|Date| Tone Temp 6? ap obcose
[3 : 136179| 90 ye
1206 144179) 83 | 22 | oetol 24
0400 lmale| aa | 20 | gsihal
Admit | SUF | ergfica] 120 23 | 96% Ea
PSYCHOSOCIAL MODES ASSESSMENT
[SELF CONCEPT/ BODY
IMAGE.
L aa -
[ROLE FUNCTION:
INTERDEPENDENCE Seaecceed —-_—
DIAGNOTIC TESTS / LAB TESTS:
st all diagnostic exams and laboratory tests that are pertinent to the current presentation / diagnosis.
Include ALL pertinent normal and abnormals and give explanation on what you are “looking for” /
“trending”.
DATE | tap TEST ‘VALUE ‘Anticipated Finding with your patient?
REF RANGE Rationale for trending?
| High/Low/Normal?__