\ OG Ly USF College of Nursing ~ Nursing Process Worksheet student: Olivia, Meitzner pate: 2) 1] 14 Instructor: _S OWES Team: _ LC of surgery History of Present iiness (HPI: FYE ilo ~ Amiod ratus]| NEO | Fall rise PE clo WRAENGS> 3 Aodominal pain e ecnestr Sie as 5 1_aha ~hasitt had « BM im V3uceks feta teste Dic of cancerous obsttuction. c Hight gas Fee, ing Cee ap neat? Wed Wate emnitone SS ——— ieee ext Talaudid Geom Allergies: NE A 5 pw 3 Current Medical Dx: YTT Coaqulo path vaivularneart disea Disease Specific Medications (name and i ication): V2.5 mes used, For HE BArrhtn Mas Tanibrts Oi @ Ptae pa ae b ¢ ni. iV: he » Tc otol Oume in of Thhibits sash aad Sectetion BWich helps w/ OER (HOME W Amity) mechanical Past Medical History (PMH): C aydiquasculay = Open beart Suracry>Vae HTN, Ahemia , Stomach Cancer, urinary bladder cancer Subjective Findings: S COmMach pain . Ste vated, hor pain, as Z| [0 Grabs Sr Bites when tt hurt 7 Objective Findings: Times Vital Signs: Include additional sets of VS on back if needed. What are the trends previous findings? 4G. HR: BZ BPs! /U3 RR O2sats: T\ — %viatoo™ 9” Glucose: | |g HR: 1) BPIZ0/G| RRA O2sats: 42% — %viatoom ave Glucose: | ¥ Assessment: Refer to BAT on what to include Neue: Alert 2 avie trac X3 /nlo confusion jNO HIN Speen clear? Cardiac: BEd.” re quia’ OWISts* No 8 {IQ fo-set, —|HCoz Low Tow Today's Problem List: (BASED ON YOUR ASSSESMENT, WHAT DID YOU IDENTIFY AS TODAY’S PROBLEMS?) P Gastro tint na DoS WAGho e 1 NOC nd Toll Lire fective coping (cant acide what to do] uigey 2 or panicHue Cae Nursing Diagnoses: NANDA label r/t (pathophysiology) aeb (clinical manifestations) A Te distess (GT obstucton eb Oatknt Ye PoCind Hai 4 Quatding Somach} express ve be havior vay Short Term Planning: (GOAL) Parkicnt wil fpoct pain to be 26 wo min ahey Wtacd. Adin’ Sato rw : Short Term Interventions: (MONITOR -1, DO -3, EDUCATE -1) AMyy education? = Rd tSter tN dromorphone = Dlaudid = Reposition Tamla. Yor Spall! wait to Kelp dT as Short Term Evaluation: (DID IT WORK?) —Rerer 30 yon pk. Ec porre ds Bain to be Blo Long Term/Discharge Planning: = Ow, Intey sort 1 T Fannin want. 2>Oxt COloStomn For Connors? or ary Ternove, Cane 4 get mote hudrients 3 start Cnt noo. Revised 9/18