USF College of Nursing — Nursing Process Worksheet student: Catharine, Whirtorss 10 /8/ia Instructor: Dy, Ledtena W)ilin = STA History of Present Iliness (HPI): CODE STATUS: aT op female pesened to EZ with 0 {st Si adiahing to her Clodanw1, Bs r s Chest pain rade Se oi Order EAE D Ar ane, Cor Over aa 2aee TINEA sean Pons actin e TE a | Cece = ieeracel| A ce bas a eet se Ness pierek sae wunmewcny [Rw movbenQne ‘Ss Sa gies ap o teh, T_ medication Allergies: JANA —7 s_ Oo]10 Current Medical Dx: it Past Medical History (PMH): QO 1 Lo f oS Ua) Subjective Findings: Comploned oF Pan word Sucsices! Imes Site. SCL 1S _ owned xi O_O Objective Findings: sns: Include additional sets of VS on back if needed. What are the trends with previous findings? Vital Si AG, Z mal Re ce BP: \31/ 1G RR: 29 O2sats: AG %via CA 7,3 SHR: SY BP: 167/71 RR: ZO O2sats: 47 %via RA Assessme' F to BAT on what to include Neuro: ao X38 PECRLA, Facies expression iS Summetccal, aypornale spe@h Cardiac: Sinus OBA, S L 6 L CfackleS ee 7 ersten Bat | Gu: Ne ee wound Seoviariey oe In 61 Sana greeffOutput: = Ni ‘Skin: Extremities/MS: tingins, Unesbevare 10 LEAL SB SS eae) Pare Outi paren a= L1G Revised 9/18