{ USF College of Nursing ~ Nursing Process Worksheet cP snudent - ) OUT AC St pare: OWS rst WS Tucker team ST) Asean: GF Lowrey History of Present Iliness/Admitting Diagnosis ecco OF SZ week § 1 cundown, D wean co SHOIP, § AN ebb 9g palpan Vea 7014 TAllanon s 4p Peytinent Medical History- A Wot? Aoninus Aue aiorquinifwor OF WU a diecile pe OKC, DHGChut DIAL Dae piu ha ty atc not Priority Medical Dx for today: OI C/t iapawowopie Grae ued Assessment: Subjective findings- (OLDCART pain) . = ROUSE OL A Cit - pa emily aS an v Objective findings- oo, . Defining signs/symptoms: AZby 3. Ur NWA SiC Gi A Co perSend, favded Guncic vd coe CON 23 Sec Sta) Ma ORD eda AO OAT OM PN SENT Ques 42 Mo edEnc sof “BiG up Fey oti Cir ote ng TICS nea Oe nets wy al exere ‘Actual finding: WIG, Gait SACL, Te, 2eF RR 8 BPCY/Ge HR Ao SPO2)oQ) %on Nj Blood Glucose: CAstessment eo iiann, wh eleu ited mm taal aumacind oc Ou 0US LUG 7 eee Labs: WBC AST GBC B) ‘ond te} ati tata Gy pir. T3837 Sy Now i KW AWS Ooch us (ae Priority LabProcedure:—Resutsinterprtatons ‘Nursing indication (pre & post): Call provider? Pia po) bg Digudt ve _fiitilg ba Revised 04/2013Problem List: Planning /Goals (what do you want to happen): Short Term | ~ Cuil infil wou Ke f jo ke av AQeN unt ata PCa L - Sena itech ON wa Gar = vizet u -Long Term GT = Ac WON ete LUT usin Interventions (how are you going to make it happen): Place an asterisk * by the interventions that may be carried ow by those other dhan an RN OLA Moines for pin ety “Fann Lind puailadale CUM TION aA ASE in WT =f4 Wuicls “no sei SSC Ie' MORO Towa Wwe IMM Motion KS for mecnon (did it happen: pi umiwiclirn oo ft Git oF wut ue Gad Won Skicl Cote Dane OA a Ut WOT NO mon On i Win oF wh Se a en ee gE a WaT pong PA a udiyy ~