NURS 2645L Professional Nursing 1 WEEKLY WORKSHEET sruoent Name IAIN Lot, pr statusDNECC _ saFeTy CONCERN: 3 TALLERGIES| a DUEL ges pyres eeeel outpuT___skrr.90) % wunch 7S re ol ACTIVITY ORDEF OF ASSIST_ ANY DEVICES, wie, W ws NA My Bay eae Resp l(a Pain Ratin TEACHING NEEDS — Identify and State Reason (Cultural, Spiritual, Sexual, Psychosocial, Knowledge Deficit) 18 Ulu Awash ys PRoreraMt and B widow. NO Abner nord PRIMARY MEDICAL SHRUCIIO in (180). ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS Wel ObSTRK Lecupemopictaer LB, Bice: stalialy, ih ole case ia fe Can develo, man a oe cau Ancde : Ww ca Chie ai ile Oe Ou inclu! z ya ie Mechanical LB0 ina se Functional re va 1 oF oH sie te teat bart £8 WOted 0 ee us FOUndhefoee eye we faggot, put tr Hy Boke “ets on ae 4 ALL SIGNS/SYMPTOMSS OF DIAGNOSIS s sa cele Vas signe 0€ peeitonity hae belly/ loot hy ee ADT SIdunt ON Wh oe CONDITION. pare had bth ae Removed ad AU On CANCER Th If Vor in documentation. One can Inept lekcoasher ron) spell pos sungtotay 0 while tauany naecor cs ‘hop oP tee Gace “at asen (are ARPT RMCHON could hAVE Ran CAUWEA FROM thy Humor SECONDARY didi DIAGNOSIS: LIST ALL ON BACK OF PAGE. ant git fue Va thHEAD TO TOE ASSESSMENT DATA \y HIGHLIGHT ABNORMAL DATA te Alert Ona oethied, NO Signs 9€ ALAC, Al snsation Iack agpec ial lin ext Romet lA. iB B.S a yours oid but sill managed tn eecatl mast Ife events! ulde huart sOunde h Bounding pulser: Geraraes kaa af it be eee Ant He 75 dt ies oc Paneer veiea PE- 17. 7° No edema pa Refill <3.éec]} Wire pee ThROUgous, Poster tibial and pedal SPIRATORY:. (ui were CLtAie- n verte. nal ta 7 Worcaitqeg fe can rae aoticut, Ne ardanne ie catiny AypouG NJv “sete Si aah ye pagan Tob LaLE & tarry Stoolhy Ree aC4e, 2 an Se ezamunrere wh Weonkiunce pote St Ope RUC ONT AEE, inimal bower sounds ( ypoacti).. 0 bed SUEY oR bareer cecuns. Weaes poe ak all timer, BUF Know ond sues stone WL BiB ae 4O. Use jee REET RooM . USlLons oR wounds dey and tot conyIaris derelict of Sin breatdoin. $8 gas Of OVD — 5 mu ate aurta: All iat [Sorte +0 Sa (wheeled area ‘ul {ly bY Wwalkina ;, rhe We on weg tamed aninicees Fut OM. 3° PSYCHOSOCIAL: attend in ing aa Huy and vuitin Wee eet Pitan a we a a Ot \ Luks. ir ee in cna ee arate ra no oe PAIN/DISCOMFORT: Down mpi ofaby pay Rinsho Aion iN aatyus and Wn geal sn Neti Eau With Minor ieee Qind Spoke clout IMEKatz Index of independence in Activities of Daily Living (Activities INDEPENDENCE: DEPENDENCE: Points (2 oR 0) 2. POINT) (0 POINTS) [BATHING ITPOINT) Bathes self completely _\OPOINTS) Needs help with needs help in bathing only a _(Jbathing more than one part of th ingle part of the body such as the DRESSING {1 POINT) Gets clothes from losets and drawers and puts gn_Hressing self or needs to be iothes and outer garments kompletely dressed. [TOILETING 11 POINT) Goes to toilet, gets on ip transfer land off, arranges clothes, cleans/— fo the toilet, cleaning self or uses fenital area without help. [TRANSFERRING | POINT) Moves in and out of be E chair unassisted. Mechanical (rom bed to chair or requires @ ransferring aides are atveptabl ete transfer. continence FI POINT) Exercises complete selF\ (0 POINTS) Is partially or totally -ontrol over urination and incontinent of bowel or bladder. jefecation. FEEDING od from pl (0 POINTS) Needs partial or total nto mouth without help. help with feeding or requires crsonef ey be done/ [parenteral feeding. TOTAL POINTS Hialy (patient independent) Q = Low (patient very dependent atneiirtte dependant rene