hyeoaes USF College of Nursing — Nursing Process Worksheet Student: laffett Date: 10/6] i Instructor: [i 2 Team: History of Present tliness (HPI): UUWj-0. / mato pet reported raz 4p ER on 10 /fo/is with wars ning ed that he heacl ° L ec _pa: + mont wos expen 4c D ‘ m c A R T s Sow physician aitpahent 420/15 and ysa: NO current pain orc aed detent res dare ol necrosis — ring nngclomfon 101.9 | prpscepgic Disease Specific iene ALOT we “ynbeak ong Keppra 1500 ma PO gi2h £TRIAX one. WY PB 1 24H plisteccl--7 gals Clon Bat Go acthma_featse wh WACL with Depanne - S.c00units Gat KGL 1 ene fusion) what TSthe aie 7a. ‘Past Medical History (PMH): Brain Tumor = had Surgeny im remove Oct O12 = lorougninn Sei7uve condition Asim digs 200 ee £ Subjective Findings: even Time we Checked Te had np Complaints eae “Em ae Objective Findings: TQG.5* HR 0B BP:143/75, RR: io 02: 48% via oom Glucose: ee Assessment. a aes Neur talking, ork ‘ons ta “moe alt cents SIS ag ao ? — Pulmonary: n L i vices O-TiNeS OF Aevices were int unaten. ——Fetremities: —_—_—— tnes/Devees Ft z scnoccied cluring mu shift because.Results/Findings/Interpretations: if extercliagfrom inferi hoe T-1 A Tlem=li kely Laproscopic Nephrect omy left kidney — scheduled for 1ojajis —necronis Common Lab Values: / ee pcos SEE ng DIS SRERET ne S075 f ! 40) 107,18, Tay 429 WS not Sure what else wias Neecdec| que Shae Prey ‘Today's Problem List: a \V Maintaining Pal Gee Status Cop LOA ecrease Sh ns chin iS on Nursing Diagnoses: LP055\ble ) Acute Pain velated to dines, mass as evidenced lay initial chief complaint beby reli c idence keShions % concerns short Tem Planing: @) Maintain WO Maintain pain level of 0 on a scale OF 6 to 10 Ofer / OF 6 tot dO Picoe Jeng - incentive spi cometry ha - 0p visit by Clergy Porsprayey : a Short Term Evaluation: Pahent sta Short Term interventions: 14:30 dhe was shil pata cz ot shift Change arouncl a Priest visiked Gatent appeared re ett hen he fixind out Saraeny me had no more questions after Shift Change at’ B20 S< Long Term/Discharge Planning: oh Sy yecovernyJ LJ Allerqao: Dilantin OP. Galea pen in TY satlori USF College of Nursing ~ Nursing Process Worksheet Student Date: 2.) 25/1 Instructor: Dana Re. Team: Tet SBN) Histor ofPresent ness (WP: Ae yo. Feraaleoo{ PMN of ce) _ A ee NOS pees: Sy constant Pfs deupage ——___ fe chan owns fio (eMink also hed.tt ferbuptoanas dnuitiocsant lace © eee ein ee a! 4 entice tee PL. CRevive of 8 wohich, ae, Disease Specific Medications: Solu- redo} G evening dl Lopressor itm, P0d PDaxdei per No Gut tet ni eg ® eenring “Torado} Pe 5132 Y Pool de iso Po = S1r€1 150mg POniejtay mi sis ( Ww a {> POdaity) Head ae S aa os : [aay Objective Findings: T91.77F aR: BS, BP: [08/55 ® RR: 1® 02:95 %via roo Glucose: ) 8} Assessment Neuro: PERELA, Ad Ox 4 Cardiac: QD Tres ar! —Putmonen- tual clea Nadu iyo odien tous sued = reports Gh; ormmodchye, OSx4 quads, no tenders GU: induperdant- no's 16% monitor ng —Fpmotlere | Extremities: Redalapeda] pulirs temp. paceDiagnostics/Procedures: Results/Findings/Interpretations: & Ww] wo Cortrast __| ignite matter: lesions -mo achive cheese lication y “_-* nate clegeetrahise Lise distace LULE,LS-G1 ral 9pit garal Ma TWaratie Spin «atone at T¢- 2 ? sm a Me comct e mi reetpectstibat hteanuteae ene! cominen ab ales Disease Specie abvaues: SAIS” Yh = Ve) eo IWR LO Pets 10. PT] aa 9.3 ¥ Hato flO4t erp y! pide / rape 4a/ ae yh oa et — ees artes free) 1-4) ala bend) o Gn eee ae “Today's Problem List: Nursing Diagnoses: OAcute Pain lal cer| deb ian a sk For injuiny relaked fo sensory, chlo Soa alata or Fall Short Term Planing a the end of ey fice buf: a n Short Term Interventions: or talkabou tal pathy. tohelp pain mandgenent each ploveclHaunay For ai 5 Short Term Evaluation: Oe hallymot as pt rated pain at Gout OF 10~ 45 min afler pain meds, but pain DLL ake (haw to =} or & before (twas tine for next ‘dose, Long Term/Discharge Planning: (Drei the pecupefane oF Sficking w) MS Yeon tommunie frateronhons lisharge, after dl ori ob pt. Of mwdicarion sie