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\N3 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?__

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