USF College of Nursing - Nursing Process Worksheet student: Oliviy Taylor pate: (5/19 Instructor: H. SHU p. Team: FHT (Mii) KeRED, History of Present liness (HPI: WS yo Male admitted sl24[ry [PMA 1 AB ar fiom SNF with qroct hamatunia. PE wastownd to [OI have no dear- pt hove Trauma font catheteriahon. PF was found Coil arteval nttyorues jo wid hove pnenmMoMg with bualeralmbltrater|D ATA Fi was adnntted Yo SS to recere Obie abs. Pi's Te IpIiaTN) C dyspnea, AVERY AGtHWIN/ Change 1 position | MAUS BEQAN decom pensn ting + wos tancierved to 3N. a RMN CA TY VECO Wg Wak 41 aWarhiag RIL R Spr Or, Siti wp | Awe _placeyn eve wt vider to Contin s 1eViNng Oby [T albuterol; budusoni de ater dit, Hemamvia Wag vesoled. S™1 Feel pretty bad “disease Specific Medications: for etme chee eS Nantomytin 1 GMAW Q SUH? wil be djeed on 4/0 atftpme Tam iv ashy 7 ‘lbulciol: ipratropinim 3 mt 4k daily mhaled vudesuride (Pulmicort Recpules): 0-8 mq innaled once daily Past Medical History (PMH): Corp -uloteral above the- nee nmeulahm, dm wrinary yerention Subjective Findings: Fry. ph comepraints ~pi_admitted frm (NF; wil be d]ced to came ONE ~ FICC team Was wiinble to insert PIL line ATE pt nontomplian te + disinphng trente Feld Objective Findings: ' 3u Lz: VIO E98 HR BY BPH na: 19 or: %via AE Glucose: We +1200 oval Oam Assessment: ‘Aleuro: AD to person, plaice, and hime; recponds to verbal Hill; slow to respmd Cardiac: He|MINt PVGeRAHR: 4 radial puliec +2 bilaterally > wppey tap refill <3sec femoral pulses: doppley iuecdere underlying vuyheoe Pulmonary: iniabored breathing; al lobes diminished, aecais wh achvity Cewest: 167.) [Gireu ibe; pureed diet “{Gisbowel sounds normoacinead, wiconhmenl Gu: SWAY foley) Mine Is ATE yellow, emai Skin: S1O1ge Hil CULLYA PV. Yash 011 wpper baci | “Extremities: bilateral AMPVRE Ane vs wast C50lves “ines/Devices: 22. (Lt) upper av Pain: pt reports S|ID pain in sacrum before Meds Other: diplet procauhione AT} MUCA wi the Soulum=s wound, foam dressing 1 plate.UUslortopy (date?) = trauma 1M vepectied catmeterzatin Alsenostics/Procedures: "Kesults/Findings/Interpretations: [za spuium cullare MESA Gh) olan: wiwind twltwre (Pv) MESA G) Hii thet Xray witatermliahitrates worseried wihttrates q [Le west X-ray “Disease Specific Lab Values: Common Lab Values: _ te = CX yo.s Awatdrsa | vote 1 32 Ut) 496 Ta.u | 88 a til Sse 7 V3 [Rea | OV) ee 8.3 oe Ke Att ‘Today's Problem List: Patient desais wl exertion | thang: im poitivia PA's satyal presse Wicer 16 very Large + pala ful PL. is Wtvntinent oi stool; ase br wivetion tor Bw Wet: 10.5, 30-4 (L) Urending T “Fursing Diagnoses: vncontinen co. » impaived skin niegriiy cts immob hity Spoor nutution, and DM dab singe Il Sacral mesure uiccy Columized with MIRCA + Tnetfective aivway cleaveice V/t Sea, COPD, and rmmolsiity fob PNA, Need toy Or Visk tor decreased tardiac tissme perfusion vit PVCs, hyperkalemia (WS mEa)) ie hort Term Planning: Phy pressure Wey ATeSING Wi MAM dean, da. + Miac thevghowl the she PRs SpO2 will temo above V7 thoughout the swift Pity V+ tevel will etnin to WM owmnal paramere before fhe end of shift “$hort Term Interventions: ~ivin_ pt 82 hour Tenange sapiol dresing at least Qdarly, more LE Viet ded admun HMonitty soz and respirdtyhy statwe, LOC thinvghout the Cwiet (sp027407.),“HFP° FAdminister Kayexalabe + ca gluconate srat, vecheck FF level tin lave Vs L “$hort Term Evaluation: TPatitht was timed OZ hve wing Tham wedge Fpatithis saural dresing vWwas changed wey nik BM Spatienl «pot iacreaced Hhrongnowt the clutt; Se02 remained S107. at vest - kavexatate + Ca qlaconale were adimiitcteted; Kr level Voweved to S.3 meajL attr Shes S Tong Term/Discharge Planning: