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    52 views10 pages

    Nurs 2645l Professional Nursing 1

    Uploaded by

    api-546707775

    Copyright:

    © All Rights Reserved
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    NURS 2645L Professional Nursing 1 JACMS© WEEKLY WORKSHEET A152 Ee STUDENT NAME _.\AKE. DATE OF CARE, PATIENT INITIALS_1)- DNRSTATUS FULL SAFETY CONCERNS Nigh Ta aiterctes_/WKIDA DIET crype/Assstance needeaXACG Coa\ol INTAKE @22% OUTPUT B2MLBKFTIOQ% LUNCH___% ACTIVITY ORDER, HOF ASSIST. ANY DEVICES. ws Rue Atm Bp___Temp___Pulse__Resp_|(o_Pain Rating_O /10 TEACHING NEEDS — Identify and State Reason (Cultural, Spiritual, Sexual, Psychosocial, Knowledge Deficit) PRIMARY MEDICAL DIAGNOSIS: *HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS EoLocyPaTHorHrsioLosr feo watery Qyskunctin (Observation) BR Gon on YfiolZ( of ome with daugnre, Se WPS AdwiedS UH lee WiP ard aAbdorinal pain, CU God wo Sagns & Goetwre bt Py hes yemurnre Unawe ko omniae. Pris aise being freded Gor ay onpitsyy UM. ALL SIGNS/SYMPTOMS OF DIAGNOSIS Void @ 0830 ( Zoom) vos@ \\o ( 300 me Wire @ over (2%) \ntoee @ ooo (44 me CAUSE OR EFFECT ON PATIENT'S PRESENT CONDITION. SECONDARY MEDICAL DIAGNOSIS: LIST ALL ON BACK OF PAGE. Pr on TWO Wsteny Donen Covws/ineal Wapereasion Eanes (Hlth) Wpeeneié Run 4S Stool jaconty MA W/ CD Suye 4 CRz 4 AS. cor 3\ De THe wee 7) eyes eaters WOR WS Cat 30.4 AAR 4 Pore wie in Place Keeraminchien 650% Po Ole heh Gl Po Every AM Ceph ated (yokes) 750m Po A eocirateprann (Lerapre) SRE Smy Po Cary Heparin Sooo units Gea OH Trsuiin Qlogie (Loats) 25 units Sra Aigyey Jevetny rorine Coyrnvers) Otmeq Po Evry Amy Preaarsrin (Lyte) Anitcon un Sot Sor Po 3 times daily Arimern alnearz amide (Thm) Zoo ray TM Ob Pe Mauser Aurosemiae (Last) Yom Po buity \ ‘TREATMENTS (INTERVENTIONS): INCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O7 THERAPY Treatment (intervention) | How Often | Times Rationale Ty Rawr Loved Koreas Pennie Dear [Crennes Sressiney ok GPO YTisT al leet Goceat oy pot — KO Ao \nconkines 4 ‘TARGET ASSESSMENT (Hospital Only) What body system(s) Why did you choose Document assessment of that system HEAD TO TOE ASSESSMENT DATA HIGHLIGHT ABNORMAL DATA NEURO/MENTAL, B_Ond (epanss enMGrdS Speci Appioptae ere De eeL CARDIOVASCULAR Movs Lycued iuevy efi let fron 3 Srtonss No Jud, AB Jalgitertions Motes, MR 23. PERIPHERAL/VASCULAR_ er Wemitte, Ll feemni HES nite 1 ot Dt 429 Qiu Gor) ALL ohter ives Que FL pilakeaity RESPIRATORY, af nei ef boilateraty thy Naoof. FQuat cuir cist ond SEaN\ aieraiy GASTROINTESTINAL All WN Ache in All WS 5505 Posted, alodomeN 15 Cand withows ascites RAS po pun Upon paipaner GENITOURINARY GEAKQ\id 75 intact ond with Mairerees ON Kronen Lot TV. Dk io AlSo incombinent wiht! ction, plaid in Qe, out @ OPP ww Poor sKiInPL nod fein kor on lett fovea feu ress pplied ect 0460, De alos Was Aeciottc tase Ton totien Re “eee A Te stick a Nr 4 tect Mayr, MUSCULOSKELETAL, N a enh He i: Swed Lawes Ookrent5 hard inired bitty ard eae Lerenchn I PSYCHOSOCIAL painyoiscomrorT__O/|o (A denicS anny Poin preset Katz Index of Independence in Activities of Daily Living, factivries lInDEPENDENCE: [DEPENDENCE: lPoINnts (1 ORO) (a Pomnt) \(o Points) [BATHING |G POW) Bathesself completely [0 POINTS) Needs help with \/| lor needs help in bathing only a [bathing more than one part of the Isingle part of the body such asthe |body, getting inor out of the tub [DRESSING [2 POINT) Gets clothes from (0 POINTS) Needs help with closets and drawers and puts on [dressing self or needs to be [clothes and outer garments ‘completely dressed. [TOWLETING | POWT) Goes to toilet, gets on (0 POINTS) Needs help transferring land off, arranges clothes, cleans {to the toilet, cleaning self or uses igenital area without help. lbedpan or commode. TRANSFERRING | POINT) Moves in and out of bed |(0 POINTS) Needs help in moving lor chair unassisted. Mechanical from bed to chair or requires a transferring aides are acceptable. complete transfer, “ONTINENCE (@ POWT) Exercises complete self (0 POINTS) Is partially or totally {control over urination and incontinent of bowel or bladder. \defecation. FEEDING ((1 POINT) Gets food from plate _/(0 POINTS) Needs partial or total into mouth without help. help with feeding or requires [Preparation of food may be done [parenteral feeding. TOTAL POINTS = | 6 = High (patient independent) 0 = Low (patient very dependent) Fulmer SPICES: An Overall Assessment Tool for Older Adults Be 4115 J 200\ ‘EVIDENCE SPICES Yes To Sleep Disorders Problems with Eating or Feeding X Incontinence CConfsion Evidence of Falls points, porto 23_A developing a pressure ucer. A low score moans highor risk, ee 2 ASK. Aazees Prior and dng a o e e o SENCORY comptayiimtc: | Yryumine una met | woman cere, [STU pans [ate | ime Ability to respond | moan, finch.orgrasp)to | stimuli. Cannot ‘commandsbutcannot | commands. Hasno meaningfully to painful stimuli, due to communicate discomfort | always communicate ‘sensory deficitwhich pressure-related diminished level of ‘except by moaning or discomfortorneedio be | would limit ability to creat | ee sat, | mene oor ieee te on sso imtoaistesinin | nasasonsyinpsimer | hx asonsy psn smeccaensege | taaimeteetams™ | eisimecapa oe rer ed er wowsTune | corearty woot, [a Costes ase, | arta MOSTIRE |S MOR men (MoE enn | Saige | Sf Mal ay Ce | Seareroantcy [Se mat | mravearesetior | increas sense Seer amete’ [raeictenens |Startreamay | amemseryet Sienna tran |e aoe ener Serine nervy carter Wat Oecesoaty | wake Fogo Segne of prystat \Eosterotee eee ciay | HESSEN ay Meester oy Cem | saeccree | Paoeticnn smetoememet, | Smears" - | meee coameeeet |Secc rch | abetwmems magma! | seeccaainn | meviccacbe meee fa WOOLY | Consiat mae saat niet | noumtaions Ability to change | Doesnotmake even slight ‘and control body _ | changesinbody or extremity Makes requentthough | Makes majorand slightchangesin bodyor | frequentchangesin position positon witoutassistance. | extremity postion but xvomity positon positon without ‘unableto make frequenter | Independent. assistance. ‘significantenanges indopendenty. NUTRITION Probably Inadequate: | Adequate tent Usual food intake Rarely eatsa complete | Eats over halfofmeats. | Eats ery pattem Farely eats moretnan 1% of | mealandgenerallyeats | Eaisa total of 4 servings | meal, Usually eatsa ‘any foodoffered.Eals2 | onlyabout of any food | ofprotein(meat, dairy” | total of4 ormore Servingsorless ofprotein | offered. Protsinintake | products) each day. servings of meat (meator dairyproducis)per | includes3servingsot | Occasionally wi and dairy products. day. Takes fuidspoorly. | meator dalry products por utwallusuallyiake | Oceasionallyeats Does nottake a liquid diotary | day. Occasionally wiliake | a supplementifoffered, | betwoonmeals. ‘supplement, a dietary supplement OR Doos not require ‘oR OR 's ona tube feeding or | supplementation. Is NPO andiormaintainedon | Receives less than TPN regimen, which Clearliquidsor Vs for more | optimum amountotliquid | probablymectsmostot thon 5 days. di hutitonel needs. FRICTION AND | Problem: Potontial Problom: No Apparent Problem: | TOtal Points: SHEAR Requires moderaisto Moves feeblyorrenuites | Movesinbed andin chair ‘maximum assisiancoin sisiance. | independentyandhas moving.Complteliting | Duringa move skin sutfeientmusclestength Wwithoutstiding againatsheets | probably sldesto some | to lit up comploteiydurng Isimpossbie Frequenty | extentagainattreshee's, | move. Mainianagood | Clinical Sldesdowninbedoretai, | Ghai-resvant,orober | posttoninbedorcharat | Judgment roquifing frequent ddovicos. Maintains altimes. repositioningwithmasimum | relaively good position in ssistance. Spastic, hairor bed mostof he Contractures,oragitaion | tmebutoceasionally feadstoalmostcansiant | slides down, ‘ncton, RSKFACTOR IK POINTS SCORE Assn hardpan Conerai, rreDti aepen ren |Confusion/Disorientation/Impulsiity 4 9° Symptomatic Depression 2 ic [Atered Eimination 1 \ Dizziness/Vertigo 1 oO [Gender (Male) a 0 [any Administered Antepleptics (anGeonvulsants): crtenarne onto Sanat, ose aba ahh ct, a L [Any Administered Benzodiaepines?® : 0 [Get-Up-and-Go Test: "ising froma Chair” "tt nes ort nga els eran entered ality to rise in sngle movement - No loss of balance with steps ° oO Pushes up, successful in one attempt 1 Oo ‘Mutple attempts but succesful 3 oO ‘Unable to rse without asistance during test | tural to ses, document hon the patent char withthe dt nd tna, A {A score ofS or greater = High Risk) ‘orat score] O} Stan andi, morons, oes a tha dS ara TEE retin apo partaneetatarnn stn eri [NURSING 2645 PROFESSIONAL NURSING 1 CARE PLAN seatane, DAME one otcareI5 260 _wedeat Dagon \rmiouiatory Ou Sfoncsi ov using Dagon: Sk Coe eu chcomse imialae mt Mleabeeas [eaionend ‘as manifested by: UC. J ncons ings Aiyierie Lveabmenr wee Wo bbe etnton, 4YSCCPHONL A Generai/Long Term Outcome: ENSUE QarienrS nkuues daily (eskrictior IScome of fividS “ad Term Gxcome | Nargis Tinie Raw, | Bauatn —| — Mescatons ‘measrae) Sone Uroreeeimervention) | "P58 | (ogres tomard Posen Wt ouomes) Toraet de HISIZF] Tenn Qogrenk Xe Fis wesrcon [MT pascert Pasa'S Raw] NE STi te ea Meaty Jos cebating Wedd pac | oe oon vatome Hews | | ntoue oon |e ts ane oom EH fa er os Sem Some | red to vataue Boiss | Yeung Cie] eo i») oe ten oon he iss | aes kvm | Mae ws ere ers] ob ETS OS || etn Gamers aunasenns |S \nsome, ‘References on back Bod [21 Clo te > FRTI6% We ~ a7 R-\G Teng

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