1UHS)2645L Professional Nursing 1 (QW WEEKLY WORKSHEET STUDENT wae E DATE OF CARES" “IPATIENT INITIALS. te ALLERGIES_2° OSM t4 DNR STATUS_f)\ S000. SAFETY CONCERNS Liv’ 2 > DIET (Type/Assistance needed) Co: orc INTAKE 2nd OUTPUT 4.00" BKFT=25 % LUNCHZS_% ACTIVITY ORDER__\) De # OF ASSIST__©. ANY DEVICES__! a de sLincnd —_ BplS7/42temp41.0 Pulse76_Resp_1® Pain Rating. IO Sp02']49 77 Ws TEACHING NEEDS — Identify and State Reason (Cultural, Spiritual, Sexual, Psychosocial, Knowledge Deficit) | PRIMARY MEDICAL DIAGNOSIS: *HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS ETIOLOGY/PATHOPHYSIOLOGY Dv obe © ¢ | Ig cerns are not avie Ae veceNE ee || spun fot du “or e jouw | °. pautate We the blood, ‘elood PH Lecor | } phuctesn | F % | ALL SIGNS/SYMPTOMS OF DIAGNOSIS seccensed alertness ernuscre SHHeres® Frac BYESTATA awry, ing exing ono! bond: pain | + \usned Fact | + pot Oy AIP? o Crake BCE | mrecdocke | ‘CAUSE OR EFFECT ON PATIENT'S PRESENT CONDITION. = Font COmplouned of Nasa 9 Shrertness OF brett in Tacmornil gaid Tay went Ouwop WT OFEEMODN. Porat draw rails Vertoviy 4 voided 3 Cums suf ‘SECONDARY MEDICAL DIAGNOSIS: LIST ALL ON BACK OF PAGE.f f TREATMENTS (INTERVENTIONS): INCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O2 THERAPY ENING TOMO Treatment (intervention) [How Often Times | _Rationale oe Wenrel Cor Monitor unre for quacog, eerenes.* wetbod | SMOGUEHE Q\wOAS (y CNC Tpit Lumen ns PALATE» HUadS Upon Ga ASN DLWOMS ly Adoni Delt. ugar TARGET ASSESSMENT (Hospital Only) What body system(s) Why did you choose Document assessment of that system= peda EXPLAIN HIGHLIGHTED ABNORMAL assessmewT DATA FROM HEAD TO TOE ASSESSMENT (IF HIGHLIGHTED ON PREVIOUS PAGE, MUST BE EXPLAINED HERE) NEURO/MENTAL ovo CARDIOVASCULAR BupecteD GF 117/62 1 BP convicts, Wigs AWrougrourt Wespitol sro, No listo of PIN. MOu be SU of \evonotyovine? S PERIPHERAL/VASCULAR W\oWrno. RespiRaTORY_WsrwiaS GasTRoINTesTINAL orn L GENITOURINARY_FoleM, Caterer removed. Bleeds wf 1° void) beet wont er Cleav wy 2! sun_noeno MUSCULOSKELETAL Mild diswrnfort in lust feas- POD” ptaud We porto Sous Moet, noel, psycHosociannocmoL 10: Pain/Discomfort Reports pain ofKatz Index of Independence in Activities of Daily Living al Activities INDEPENDENCE: [PEPENDENCE: “| POINTS (1 OR 0} {2 Pown) (0 POINTS) BATHING {1 POINT) Bathes self completely (0 POINTS) Needs help with forneedshelp in bathitgontya bathing more than one part ofthe ingle part of the body such as the [pody, getting in or out of the tub lORESSING {L POINT) Gets clothes from -) (POINTS) Needs help with Josets and drawers and futson _ fressng self or needs tobe Jothes and outer garments ee dressed. ITOWLETING POINT) Goes to tolet, gets on, [0 POINTS) Needs help transferring| nd off, arranges clothes, cleans to the tolet, cleaning self or uses benital area without help, jedpan or commode. |TRANSFERRING POINT) Moves in and gut of bed [0 POINTS) Needs help in moving + chair unassisted. MecFanical from bed to chair or requires a fransferring aides are acceptable. [complete transfer ‘ONTINENCE. POINT) Exercises complete self (0 POINTS) Is partially or totally kontrol over urination and incontinent of bowel or bladder. jiefecation. FEEDING [1 POINT) Gets food from plate oo into mouth without help.) Preparation of food may be done (0 POINTS) Needs partial or total elp with feeding or requires arenteral feeding. 6=High (patient independent) 0 = Low (patient very dependent)developing 5 BRADEN SCALE - py Saeaeerees ¢ SENSORY o PERCEPTION Completely Limited: Ability to Unresponsive (does not Nery Lined: Slightly Limited: 7 y torespond | Tiyeehonsi Responds only to painful | Responsive to verbal Responds to verbal Meaningful to | Moan. finch, orgrasp)to | stimu. Cannot commands bit cannot | commands. Has no pressurereated | bo stmt deta communicate discomfort | always communicate | sensory deft which discomfort male level of except by moaning or discomfort or need to be | would limit ability to consciousness or sedation, | restlessness, tumed foo! or voice pain or ae ‘oR or discomton | limited ability to feel pain thas a sensory impairment | has a sensory impairment 2 over most ofthe body which tnt the abit to | which its aby to fo! oO surface feel pain or iscomfort | pain or ciscorort in tor Covor V4 the body. Dexuemtes. MOISTURE Constantly Moist: Moist: Occasionally Moist: Rarely Moist: Degree to which ‘Skin is kept moist almost ‘Skin is often but not ‘Skin is occasionally moist, | Skin is usually dry:_ skinis exposed to | constant by perspiration, | always moist. Linen must | requiring an extra linen | linen requires molature Urine, etc. Dampness is | be changed atleast once | change approximately | changing ony at ~~ | detected every time patents | & shit once a ey, routine intervals. moved or turned. ACTIVITY Degree of physical activity Bedfast: Confined to bed, Chairtast: Ability to walk severely limited to nonexistent. Cannot bear own weight ‘andlor must be assisted into chair or whoelchat. | | Walks Occasionally: (7 Walks occasionally dui day but for very short distances, with or assistance. Spends ‘majority of each shift in Walks Frequently: Walks outside the | oom at least twice @ ‘day and inside room atleast once every 2 hours during walking | Usual food intake patlern Never eats a complete meal Rarely eats more than 1/3 of ‘any food offered, Eats 2 ‘servings or less of protein {meat or dary products) per day. Takes fluids poorly. Does not take a liquid dietary supplement oR is NPO and/or maintained on ‘lear liquids oF IVS for more than 5 days. Rarely eats a complete ‘meal and generally eats only about ¥ of any food offered, Protein intake Includes 3 servings of meat or dairy products per day, Occasionally will ake ‘a dietary supplement, OR Receives less than ‘optimum amount of quid diot or tube feeding. Eats over half of foals. Eats a total of 4 servings. of protein (meat, dairy products) each day. Occasionally wil refuse a ‘meal, but will usually take 1 supplement if offered, oR Ison a tube feeding or TPN regimen, which probably meeis most of futtional needs, bed or chair, hours MOBILITY Completely immobile: Very Limited: ‘Slightly Limited: No Limitations: Ability to change | Doesnot make even sight | Makes occasional sight | Makes frequent though | Makes mejor and ahd Convel boxy | changes in body or extremity | change in body or Bight changes in body or | frequent changes in| ie poston witout assistance,” | extremity positon but | extremity positon postion without —~ | Position Unable to make frequent or | independently assistance O | "Sonifleant changes Oy | independent. NUTRITION Very Poor: Probably inadequate: () | Adequate: (-) Excellent: Eats most of every ‘meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals, Does not require ‘supplementation, FRICTION AND. SHEAR Problem: Requires moderate to ‘maximum assistance in moving. Complete liting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spastcty, contractures, or agitation leads to almost constant friction Potential Problem: Moves feebly or requires ‘minimum assistance, During @ move skin chair, restraints, or other devices. Maintains ‘atively good position in chair or bed most of the time but occasionally ‘down, | | No Apparent Problem: ‘Moves in bed and in chair | independently and has sufficient muscle strength to ff up completely during move. Maintains good position in bed or chair at ieee EG) Total Points: 20 Clinical Judgment Low Rie 21 20SK FACT ise RISK POINTS, ‘SCORE (Confusion Disorientation/impulsivty * lo ol Symptomatic Depression 2 ne) Altered Elimination a \ Dieziness/Vertgo 1 |o Of Gender (Mate) 7 , 2 7 0 Any Administered Antiepileptics anticonvulsants: : i coarse, hipoe Stu, he Caan eta xen, 2 0 O amare eheryon, rnsnay eat Peon Pons oe [Any Administered Benzodiazepines” Worm. Criss Connon, Cases Dts Das, espa [Get-Up-and-Go Test: “Rising from a Chair” tite ses rt fechng ny el ss oh ton came thane wh et ad ie Ability to sen single movement - No loss of balance with steps 7 1670 Pushes up, successful in one attempt 1 Muitpie attempts but successful 3 Unable to rise without assistance during test ~ unable tases, document his onthe patient chart with he dt nd tine. : [score ofS or greater = High Risk) Torat scone] 2 J [5a finda ghee Sins ae, 7 DN 5 Pet VR heron py nd pried trl wo aren vent ee ea ate na fbr nga nn Nn en nn tgNURS 2645 Professional Nursing 1 - Care Plan student: Pri2x I GVA MOV eSOnvate ot Care] ZS) IO Nursing Diagnosis: Deer vrowledae Published Definition _Alosencs oF Ae-Hcvencsy MEGSES 50 8 SREORC EIS. Ft Ov of Compliance | Meaical Diagnosis:_D ISVENE VETOOUGE Ty oF cpomitive (nto nc. as manifested by. ‘Short Term Outcome (measurable) Patient will: ‘Nursing Interventions ‘Nurse wi scommlder Cordtat yrening, o describe insuuns: bene used and Feason forthe aud order oud wit PRESAU Ho korenedhOn MIL Ireutin Is ber Odwninigtered. 1 duwing shit ° desert eee + celnforce leatentigg Anvoug Svequaent SULA nnd FoliDUs-tAR cele Sregroiay [+ Hive pt demasieete '¥ dumng Corre & Lecnniq Rationale {for each intervention) od inn Neds cotion ourcenatt £ Evaluation (progress toward Modifications AGUDIN oA i ma paned: qiven ben UWL Wrurachor sotun wi men's 2 Qoak met. Wan hap of pryadany Pooeuk undavctaba ee rasan Veeanned Poin way RSCADY EL