9822000 ‘ fe : tag thon Ahly ) = [bbe 555 pli N220 - NURSING WORKSHEET 70 RN Gard all STUDENT'S NAME: _Vivian Pham pate_A. ae aS fe me (ptt atival siuation /sacksrounp; | /peqlans aymphoale aninie Yh awe varias MBL ace & sex_[__ apwussion vare_4/5 T5o: fo! mnuvanvancunce_Spe noes __AUICN —_covesrarus Gull 10:2 athyp HISTORY OF PRESENT ILLNESS: +4 ° CHC, pabvonay era, PRA oy hats. sor ofthe patents iness/grmptms that be i them into the hospital focay? Gyo M rent Cra gf uke Ph fad (coat eel hil ; ds PCC bine, recainin TY Y oscar it Plowumnanecr Ha Ulfimson aby awucel an > natn es telat gs Pekaipiiad 4) resgragl sal conte Aly oars Vee a ein, shel prin, ly, Puce, Hae same Herefays, to Other feportec acral corr A COURSE OF EVENTS - cuter of care, eve ani, singe admissions: be. suc f carived beider line spss odelu I qe soll tapas epageunival 20 ound Fol. TV NS 50bee odristered to peal naie> (ade 22K" hb 4.1, Krunboey bout £330, (adele 24 ,cxR: vreae ee fas pullac! pic beat @ L bare. vane, nA a os AS, & tyrd cerned iar i on of pater desah taococre, INAS deca, endaeord onal en Jed te preven be Abe defen oat, ete ogra gael plato O'RELATION faked Book BETWEEN MEDICAL HISTORY / CHRONIC CONDITIONS / IG MEDS thgt intuonced purrent gondiion’ he distesh, sons overdue = saps oh SEN af Rett FR cy Nhe ans fn aces hele eh ae ae ee tdsteom 4 a te pchod ee calle ata chain rath or ig dng Wy piss cel aol cis atic, up failure, Shrek (ole of entre cei en Jane for lh a rary a Sag ee tT fey Hoc flows «Fan ae STORY! (smoking, EFOM, aeate Lia) use, etc. (Wy IVd0g ar tobacco usage adwittd , Pkokelabwe wnt Ife eeata re sciont abana enfant dal el nbn cf elister on oe afte ae, fren senatll clots. Ancae bic raclataeon Marte A id ( His te fee ste raga gts (ae ese hy a me eh % rox seer ale een fria, 1g, acct snflarmasar, "apg un) Tet 6 oimunale the erdogends or'exogenaus wanes of fe dnault Oe ‘SURGERY? IF in DESCRIBE: 1, bn {oe Hein, 00 fs of inf cen. cle hare sable root << eat = cay el lee, ea ec ee NURSING ASSESSMENT SHEET vegla- Hott Hie, cleniey corral Thiliiahin deci 90 “alt 7.0 pecs : sari featncted ue 240mg ol 61D mn Iv Fern ret mane St le fowe,Bo a tide reap distess Pain ieee PERRLN nexroc ae efeauncr hc ailley , 7 jal ck vy.dlow oomband , seplace Kae Roy Adaptation Model ~ Physiological Mode __ PHYSIOLOGICAL MODES Lao war Ao MUMUT,| Slick Fachupnta,, cra Perfusion (Gas Transport) Orrgenaton (Gas exchangg) | Nutrition denhaibad fos on Clg]. | [ze en: | ene ase Neen a clr, abred beethig | ateytitves | fe L enturg skin “tugpr poe h _urdderwig ht | jaw Loc «3. |. mucin aa ppt RE te alu | pare "re Pie pleas L Ate Yoof meal | | Wo fain bitte [gych WNL or | sin cl yp | Able fo fect him vethoicity ray slo [stoma hast grips pot rally senterking int at Elimination{Urinary and Bowel Elimination) + ale ta, no teboul, Pins i We | alo, |nendskndd,notocema R gran Rego era weakngas, idesen [Pa sre Fk Parton inl agen! |_cakopnenrelt Fr extvonrtt Wado " Lie ard sing seule winatng tanking ein ugpr Tissue integrity (I ion) a fi my ft iter) nb 10 : |= CO wl ovintarce Rani leer {jor |- walk cone oe 14 ‘Glucose Regulation (Endocrine) - Nan diabetic L Normat Blood gluco 'W/ LINES / DRAI e INS: DRESSINGS! DRAINS: VITAL SIGNS TRENDS: (pertinent) | Date/Time | TEMP BP ‘AP RR ‘O2SATAprgey BF [Laule2 | gz | 26 [55 | iss | Alto os oF | iasisg So ag Ou RA aol 91.7 [reels | ez | | zea NS 95.4 | iezig | 34 19 96K PSYCHOSOCIAL MODES ASSESSMENT SIE CONCEET ‘/ BODY Me di uly — a TOE FONCTION: Dal 1 TATEROEPERDENCE - _ to te on Son DIAGNOTIC TESTS / LAB TESTS: List al diagnostic exams and laboratory tests that are pertinent to the current presentation / diagnosis. Include ALL pertinent normal and abnormals and give explanation on what you are “looking for" / “trending”. [ate Jia rest [Value ~T Anticipated Finding with your patient? — | REF RANGE Rationale for trending? _[Higd/tow/ Norma | ] Cetrseconphgrenataa bullae) ag KR abeorwal — in beth spate. patel capi Eton pyarens t . J air dh gina In Cai IMiasite anit of h Ran anomie due dil | Hemsley oy 54 AME Abe gn ates iyi alte, __finierapie anemia small REC YNE duct ¥ Tron Dasing BPR EN Ie ulated | FRET 5 Bq feyslavare onsciat wf cigar 4 Oy5oT OTT CRN no cougfettin < Hoven ds _ @. _@ cent for Possibility of elols fern WER TS IT TS OaT Sepsis a eaat ogi prem) reaponye He snfethon, «nffant reeciantes Mager inertia co WACs ANS | ROC: Pasg | 8) 9 Jers dets symptaratc anc ht fo polo ala | . HUH 4.1/9 ab Mf aNad otind: "ye $R6C uckecate hypecitnfa occur xpi arg oo) z 4f9 od oO PY diemtThave 8 ARS? cov 3 alg AEE i) Hy tect aspen cfg Pt don't have TB acid fbA{W | Chun 7 Exiclerce dakylectinn t (t el bai ls ) ie | > Pam sept, wi erl@expecl pl Bae 7H BON. 4{,1) 2 Lue ts Nllhagon Dede OU eth V he ow afi, low POW encticates Ava. Over mda mage’ . |evidoace ¢ bord clots, SRE Tied hs Aly | Dedivowr | Elyvated 1.027} | ed al Gu lab value bowed ar DVI, sins et frtoluw Al 9,0," \ : 1 ena trad hype | @ a nats te be con trlledd o¥ 3 | 7m in as S lactic acid ap e | \ loon | {eon 7 | Abt lg his h ieee ; 7 [Albumin Fey 1 raj haw Giver pie. KpSKeC can ut fo oxen faire foreudrg tiver), cat, UE Ropers isacee wpa ol Buns Nn SAFETY / FALL RISK Collect assessment data and cluster the information to determine if there is a problem or issue R/T patient's safety. Complete the table. TET oe ee emcees Ate geen Ses cit @ ba te might fa fe types ji it bee of | ‘COMPLETE A MORSE FALL RISK SCORE Te ei Mae Foliscore* 44 High Risk ‘45 and higher ‘Moderate Risk | 25-44 Low Risk 0-24BRADEN SCALE - For Predicting Pressure Sore Risk eorrae Sruatemmice ment | ADEQUATE fare =n SScpevermeretian 19 | toe acomete ret od core Bea fer encom sbout ran aera SiS uervegs oetoF ‘tetany wee © Seay sopranos | pmomtF¥a tows pont A —— rareanrer—] | protean wes Sincere Srhetinne “SEVERE RISE: Total score S39. UGH RISK. Total score 10-12 ory MODERATE RISK: Total core 13-14 MILD RISK: Total core 15-18 eres RISK FACTOR SCORE/DESCRIPTION ae | espones cmp (doesnot moun tno | simak Cant lewelte penn remat | commute dsconton | aves communcate Si'mommanes icot | eeeyrtymonngar | Sorento orneedta se | wou er ary rte ‘eden, on on | socom eos anny wtet pan | when suey te | meskes whch Sts crermonotbamy | felpunerasconiot | abenytoleioen of sec ete a eeomborin ier? ROBTORE CONSTANT TORTENMOBT=on] 3 OCCASIONALLY — Devertownch | MOIST-Sunntegt | Roten ntnot aways | MOIST Sin = Srecmomtte | momtamortcensurey | moctuner rusibe | ocasonay met, nace Srperoraon ures, | Cunged ales oncea | reqarmg an ers inen ce damgness wereced | Sh Saree weary Seymepmte | sce sy TREATY T BRDTAST-contved | 2 CHARTAST- Ay Ongre aorta | toned tole severe nee Scrcmec alr | hat whe wou ——| VERY UMMTED=— oer Maaeseccpera nan: | Makes neon ough sracore nest rot | Sign chases bd boston fry onion at | tei tan esteem hanes Sipe ate Ce adonclansetron Gopian) 4 amy PO deuly | Po Amesytkg od Yor‘ coral omy x0 Ved) fajedex Con's doi co fected pipscaatin sey ven cx, briny or 7 bin, sont yin -> ves Cetin feat sea | nf (arco) Vancemyean Sv | eine hth Rooerh ev ces.Dos 4 5 VSG ASKMENt aN a 7 i Sul cbneal aul Ber, [po eis Eee Pesan yen . 2 Fon, [torte il 0,pelpateVodder sr sculranie slonly Olamaspuat | TM BOER ' Monier Wiran, Coe [frei OTC wry (2yPREXA) | raphe (Org (0 PRN : ' antene cost tel ; pivicadl Phere irlieued, (Oucolee) | ceative re fl UM mF Rupr 4s Eimbalanee [LS Lu ED Ea revutle cramps aur, aK tel apie, exept uct Mile dtd ged Tega ery \ Sain 1 BEY A __(Reroquek arti [ven ES yon ldeding, ST ie partuhiila, Rise pHuf ales or@T ik | Aad pear, afeche cafe ifepud) ae se ain wpa a awl, | feral) * , ; = - fattcrk fumateresis, OF stot ae rah di ikon 1, Lwien Uefa: LET bilinbr, — fom'4 excord 7 4a fd Acctamitapled G50 mig PAN hs fopaae Y sRatibncity ad fo pom, feap| Apel opel cick 10 lef, Lpodtt whe atthaf ove | | roe St. 2UFe Je a EAB pan bel products, horhale deocodne tapi (were) 5- 325m 0 gate fn ee aim 7) sd rks sis Ped on Coste pte ure Depi s on CS + dat aun pan gh Mi, + Fae pain (cud @aAST) cel 4 tin a dapencle Hani VS, iver renal | Report Crs chongy, abl . mbclenseqpedarh de cL s week ce zeny deony tat ces» OBA aprsfande‘CJM Interpreting. Clustering Related Information What interventions you will do to address the problems/issues Fluid and electrolytes Perfusion Monitor CBC, WBC, RBC, PLT, VS, temp, CXR, lactic acid, TSH, bacteria culture, BMP, CMP, AFB, fungal culture, blood culture. lung sounds, wound culture, infection sites ‘Manage: ID cause of infection & causative organism, IV abx, IV fluids, 8S control, antipyretic, wound care, treat underlying conditions such as DM, malnutrition, HIV/AIDS, other disorders that compromise the immune system. ‘Teach: be aware of HAIs, understand basics of injection practices, good hygiene (bath, hand wash, Clothes change), clean environment & equipment, medications (indication, SE) ‘Wonitor BUN, H/H, mental status, LOC, skin turgor, mucous membrane, serum electrolytes level, Na, | K, ECG, ABG, Cl, Mg, Ca. 1/0. BP, Pulse, urine concentration Manage: isotonic fluids, NS + KCl, strict /O, nutritional weight, VS, hydration, correct Na/k levels, manage under | Teach: appropriate diet, encourage fluid intake, follow-up vi Monitor. S&S of decreased tissue perfusion AMS, LOC, cap refil, heart sounds, radial/petal pulses, edema, VS, ABGs, H/H, BNP, BUN/Cre, electrolytes, PLT/P speech, absent bowel sounds, nv, ‘constipation, abd distention, pallor, cyanosis, motting clammy cool skin, ulcers on feet & legs, VO, D- IV calcium gluconate, calcitonin, daily liseases (kidneyfver issues, CHF) \glycerin, HOB elevated, hyper/hypotension tx, blood glucose nologist & cardiologist, legs elevated, keep pt warm report SOB, chest pain, tVa, blurred vision, n/v | on “Monitor. RR, ABGs, depth and effort, labored breathing?, SpO2, lung sounds, cough, sputum? ‘Manage: Administer Oxygen if 02 <95%, collaborate with RT for HHN Treatments, Administer bronchodilator/steroids/anti-inflammatory meds, suction Teach: TCDB, pursed lip breathing, energy conservation, head elevated in bedCJM Interpreting: Managing Potential Complications For each of the Complications you identified, plan interventions to prevent those complications!from occurring. Potential Complication Interventions to PREVENT the potential What will you do should the complication occur? | ‘complication from occurring = | _ Admin E fisof a 64 —Naxoprersss ymairtain adequite 6P S chen Se eae + dn fl amare mee 2 | [ : ' “lag) (riveal care posing , Onyx | rr POE mp acaba HEB | sr Hc Cece TR ached pote Horoyy | y = Tgtglycenic conte | jon & perfusion rAd cada ty softening of pce rec $80 Jilly wel mont dsq —— Shrmig dose of WV abe Let - eto le 2 fidal veleima fo aiyway F et bygean(pcpion IE prover fr o feck fr sips infection” SE of aby Sram fae ea Margy c0F0, frsthunerCJM Interpreting: Collaborating with Other Healthcare Team Members AAs you work through your day, think about aspects of your patient care that re ste lowing table healthcare team (HCT) members. Which member What information will_| What information do you Actual collaboration you ofthe HCT will you share? expect to carried out | you receive from this HCT collaborating with communicate ember? other HCT members with? wl dattan | dict | lealhin MD gor abn tab values plan anaced} unedy ordlee