= Omang | USF College of Nursing — Nursing Process Worksheet “bladder 5 student: | iV C pate: JO] 21 | 1 pach bes Instructor: Ey IGFIn Casing ve Team: History of Present Illness (HPI): Chet complaint = Bilateral hip Pare Peason-for visit: UTT Wve his. Ne es when ulagn i Aigiene pir tis Suita drugs TEAS a] Current Medical Dx: ey t Disease Specific Medications (name and indication): AY A (adie = Hitti med a evod op a. £ for PEE on ASR Levenar: arti coadulant. eames Smneoeeay MGIC Re NA fOr CONS pation Past Medical History (PMH): Colon Cantef. AFib (Cardiovascular y. Parerion’. eth eH S copestatus: DNQ «|a]=]>]o]o|-lo us Subjective Findings: OSEca it Ske, wid pain No omforrabic 7s Objective Findings: Vital Signs: Include additional on of ‘on back if needed. What are the trends with previous findings? T 4G" ur: CY FOF RR O2sats: IY — %via 2L-07 Glucos Tr 4B. wR 57 (4) ee RIO O2sats: TB — vial 07 Glucos Assessment: Refer to BAT on what to include Nor 430 2 Normal Batt, Yequiar rinhne Pulmonary {ANOS QJ. Cea hespirarions slighty Tod fed, Bud Ye SBands prety fuer Preps Gu: night Output 100) mL Extremities/MS: {een WiTaGr. Al 3. €/Lines/Devices: I> Aud ADIs:TuCn) DF, psd SCs _Aaiviy FOL aS ae fall rise ee PAS aM, § uppeCk SSE CW. UNING, CORAGEET Revised 9/184 resection oF Smatl 2 pou Diagnostic Procedures Results/Findings/Interpretations: Abstnachen? - Lee meraes Hernia TL! anett eG ae Vowel mS enone’ Aghoh 7 stignt Tv = TWexiBaere eueeaee Hon) found. severe hyde reph rosis Common Lab Values: Disease Specific Lab Values & Trends: 1! WN gg LOT [OB ie _,7 7 ‘n> gs 3.8121 10958 lose ntl? Today's Problem List: (BASED ON YOUR ASSSESMENT, WHAT DID YOU IDENTIFY AS TODAY'S PROBLEMS?) oMawrtdaining Skin Mitegery Gite She, 1c basi Ca ny Y ODIG . F S65 loch u eave J FO Wee KA UT taeX sabi jagnoses: NANDA label r/t (pathophysiology) aeb (clinical manifestations) G pertorm abe mitglddnce Ci dementia 3 par EnASons ach" oe Mia ath NSt_Erowiig ar a Fre Tht Lt oy i ie ial luc OR Tract smoutn wpe wioisk Ns, 4actl Short Term Interventions: (MONITOR -1, DO -3, EDUCATE -1) * JIN ne Come, We emote’ HA, BP Geos ete seu SGCRCAUIC CVETY We SPT Will Come Ino assist U[ moving To Chair eteoent to PEP CAYO) Short Term Evaluation: (DID IT WORK?) *No redness porn Ther aSSessreunt = monitored. VS. errpaty Tess dry Long Term/Discharge Planning: Tone, ol 7 gy home Grell AMA Fo bewexe Sligikly pote 2 farctedl Fumi Rie AD (eri to ALE Ne, goual Revised 9/18