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USF College of Nursing ~ Nursing Process Worksheet (Assess, diagnose, plan, intervene, evaluate) Med/Surg suden CAVEAT AYLI owe S3U09 renee DD OhArD ream,_U AT agotdentce: female 54 years old Cau Considertions SANEAINE aggs of baat History of Present Mines/Admiting Diagnosis wait foe 1 sub dua te Eardiae ST year old female patient wag admitted wath Complaints a ele 0 TU years age af dyspnea on if 73 Renee Way vevented viqht sided . “potumsnsa, Tatent war emATeA and nas van ey hee 1 shgginess of breathy Ghidiele AAT, whim with woe ha a preweasiy Gaeduled upp Say yout ieatiel stpavation of the mitral valve. Symptoms ot premmonia © rgntness® Think about ie raatral valve ToMmorrW at OF3D. Current veyinen st A, sHonaes getting, meds: : ate tachycardia, auessecl, AVLs Storage ginuitevoT= pratre frm COWMNEE] WW We Se Rooting, BErees comming \wnciley Meant Calmeterol (Adyar) BLD Vek eRe mospitaihelps fe 9 Nevapamit zu mg tae BID TCatany Tecon wien oreatiaing pan Done 1ma BA HOA PEN baTE PA Aes Veal oad Sh PORTE RPP OPIN 50 a Medical History- Co. ana series” aoe Cnvoni, Ate, tHE, hyperhpidemi a clic eae PAIN Fvtsy pA TASY Medical Ds fortoday: Ax filo ¢ Lacy tarvdi o cing sgolsymotoms for dagnsis: : ; Defining senor: FRM ny Caveligy dtevensedd SeOa. Levels exertvewal Ayepred Assessment: Subjective findings- (OLDCART pain) : SubictveRadings Oe ART EUAN at Chula woR WL wnyary , \elt side oF ney Dock iadiating wpmwacic, pam lacie an doy, feels hight laydian “Ta Stretch it bik Vibe T'mg oxy todone jairc away pin “Lunngl cVely, Poin goes jo a WO wHen doing avhwvittes ite dishes ov standing tor Tong time yt Objective findings, aL. . Vents ABeey 28 UTE {1bD | AD 430° vm aly \) wi Nome cial finding: |, la as Gguned Mee 1% Bett (78 we 3. spo2 34 90 RL Blood Gluwse: VE nee Assessment N¢WrB AE 1 At Wks erat x todial pulses's iat SARE SpSc amewited pL repo ls mur mar, eat Vaid ot Wear iD PeaMT paliee ty blak se spammed LEAT SE THES “reat FUL ish Raa eV cemnds Aormoaclive, 14iy 8M iP th on Whe tyening: ST sive tut nent 5 1HCr void W3i]14 © OF, pl repo’ RE ae Ae sal in jig Mesming TA ant wpety foremem, clean dry and N quadrants? Revised 12/2013 USF College of Nursing ~ Nursing Process Worksheet (Assess, diagnose, plan, intervene, evaluate) MediSurg _ LalyProeedure Resultsinterpretations: Nursing indication (pre & posd: Call provider? VUoCnest K-VAY _ Rig} sided prummonia QTE _ tmitvat Thicker ceded Mae vepiacement 207% : ‘avlia 100 Problem List: C0430 es: 2053 ‘ rete EINE chin Waiver toatl prin Tee lle e cVyt ACURA a Pe 40/20 oe ‘mypona wire be 4 {can alma add ATT the whole shift Th patunt wed tht LS Twice Peplratoty pviid oleqining Treaiments Revised 12/2013

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