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1
Name K l ^ LeKl TtiVMA<.
Physi cal A^^^essment
1
Car e P l an #
What doeslliat paliejil look like toyou? Your first impression ol l l i e palienl and their family.
Donot judge them. Observethemand learn how toadjust your caretothe individual needs of thepatient and family.
lelemelry
heelchair/Cane
I nl fgumcnti i ry: TissueI ntegrity Neurological: Cngnltinn & Sensory
Ni)niial
Al ert _^
Oriented totl^erson/l'lacc/Tiine/l'venT
Pupi l s(PERRl A (Pupils liqual Round Reactive to Light
& Accommodation)
Behavior: Appropriate/Calm
Af f ect:d^rni aD
Memory^glmrt T^^nf I ntacfLong Term I ntact^
Vi sual /H^ri ng^Ngrf ti al ^ " ~
Speech:(Ciear
MovemenfC^ovcs Al l lixiremities mHii Equally^
Facef^nni i cl rl ci i l .
Sensory: SciisiHioii I t|iial in all Fxlremilics
Ahnoiinal Norma
Not Al ert: Lethargic/Stupcrous/Comatose
Not Oriented to: Person/Place/Time/Event
Pupils: unequal/elliptical /sluggisWiionjisaCtijie.. ,
Behavior: l rarogte/Agi tatedI^^^PQ3fidJ*
WitlidrawiC^nxiouyi^eslless/Paranoid
Affect: Flat/Animated
Memory:<gTiort TermNOxTniacSiLong TermNOT Intact
Visual/Hearing: Ueticits/IJ izzmess
Speech: Sliirred/Garbled/Unintelligible/ Mumbling/Apliasic
Movement: RUE/LI J E/RLE/LLE weakness/paralysis
Face: Asymmetrical/Droop L7R
SensoryrScnsalK^n dccrcasa1>!inequal
Ahnoniial
Skin:^ntact/Norinal C'olor/Warm/Dry j
Turgorn^ormaiJ
Skin: Cool/Moisl/Oily/Pceling/UaiidrulT/lxchyniosis
Turgor: Tenting
I ncisions:
Wounds:
I xsions:
Ecchymosis:
Drains: llemovac/J ackson Pratt (J P), Penrose
Cardiovuseular; i'crfusioti Mtwctiloskeletal: Mol>llitv
Normal
Puise^rRTdial +^edal+-rQuality: l+/2+/.3+/4<-
Rhythm: Kefful ^i l el e?: Normal Sinus Rhythm)
Heart Toncsaj TJ CTClega , ^
Capillary Rerdl]C</"'y^conds RDE/RL Ei l .UE/L L i r>
Edemaj ^^Sne^
Skin/mucosa Color: normal color/pink
Abnormal Normal
Pulses: Radial+1/+ /+2/+4 Pedal +\0hA
Rhythm: Regular/Irregular, (i f on telemetry: Actual Rlivijin^^
Heart Tones: S.VS4/Distant/Murmur Qf' ?AC^dO
Capillary Refill: >3 seconds RUFVRLE/LUE/LLE
Edema: I +/2+/3+/4+
Location: Generalized/Limbs/Facial/Genital
Skin/niucosa: pal^^'nioltlctlpiirptc c>'anoIic Cc^ijg!^^K^lV^^^fk'^
Muscle StrenPth: Rl l i ;/l .1IF^/RI ,F/RI IF SIrom.
Rangeof Moti un(RUE/L UE/RL E/L L E F^FuTT^
Gait: Independent
Transfer/Reposition: Independent
Abnormal
MuscleStrengthfRUF/L UL /RL E/RUt;: weaknesi l j
Rangeof Moti on: lUJ F/LUE/RLE/LLE :
Decreased/Weak/(,^yfitraclLires/Rigid/Tense
Gait:<Staiir6v Assist (SB/\"Pyalker/Cane/ Non-Ambulatoty
rransi?r/Reposition^Peirsoij J 2 Person
Respiratory: Onygcnalloii
Normal Abnormal Normal
Paiychosncial: Mood& Aifect
Abnormal
Chest Exi)ansioncSynnnctricaL^
Breath Sounds: (on inspirationand expiration)
C1"UL/LLL/RU L /RMI V RH j f tl ea^
Chest ExpansionQ\synnncuTca[ J
Breath Sounds: (on mspirjition andexpiration)
XGL /LLL /RUL /RML /in:tr>
El tort: (Rest/bxertion) Unlabored
Oxygen: >90% Sp02 on RoomAi r
Cough: No Cough
iimnisliedK'oarse/Ci^kles/Rhonchi/Rales/Wheezes/Rub
Effort: (Rest/Exertion7.aborejl'Acute Distress
C/O: Shortness of Brealli/Urtliopnea/Sleep Apnea
Oxygen: Flow rate- Modeof delivery-
Cough: Ineffective/Productive/Non-Productive/Weak
Sputum: None or Color /Character /Amount
Other considerations: SQ cmphyscTna
Objective: (What you see)
Calm/Senseof Humor/Appropriately Dressed/
{Wel\d fo^
Occupation: jZniployedfReiirej >
FinancialQnsured^'rimary or SoleIncome Earner?
Home: Hoiisc/ Apartmen/ Alon^Witli Family
Social History:^lealthy Coping Mechanisms^
Support System: ^mgle/Marned^amil>yi'riends
Objective: (What you see)
^nximisj Guardedy Inappropriately Dressed/Disheveled
Occupation: Unemployed
Financial: Uninsured/Primary or SoleIncome I iamer?
Home: SkilledNursing Facility/Assisted Living/Homeless
Social History: Tobacco/Alcohol/Recreational Drugs
Support System: Divorced/Widow(er)/Alone
Gastroi ]^ i ti ati un & Metabolism Pain Assessment: Comfort
Normal
Bowel Sounds:(V^lormoactive^
Abnormal Normal
Diet: Cardiac/Diabetic/Fluid Restriction/Other:
.. Noimal
El i mi nati on:^oi di ng/Conti nen^^
tri ne Characteir^j nEaCT^irTellow/Normal Odor^
llntake= OutpuQ
Appetite: Poor/None/% Eaten_
Last BM: Abnormal:
Color/Character/Odor/Size/Incontinent/Rectal Tube/Ostomy
Mouth: Dty/Poor Dentilioii/Pain/Sores
Abdomen: Obese/Firm/Distended/Tender/Guarded
Bowel Sounds: Hypoactive/Hyperactive
Other Considerations: Ostomy Stoma Color
Tubes: Gastrostomy/ J ejunostomy /Small Bowel FT
J jibc Feeding rate/residuals/ TF mlakc
Genifourlnary: iJiuiinalifin j j ^ ^ ^ ^ ^ l ^ ^ ^ ^ ^ ^
Abnormal
g^ainSti^le:(L->>
Pain Management Goa(/T5eniesPam
Abnormal
Pain Management Coal:
O: Onset: Sudden/Gradual/Chronic
P: Provocative: Movement/Pressure Palliative: Meds/Rest
Q: Quality: Sharp/Dull/Crushing/Burning/Tearing/Aching
Intermittent/Constant/Throbbing
R: Region: Radiating to:
S: Severity: Pain Scale: 1-10 scale /Faces / FL ACC
T: Ti mi ng: How Long Recurrence?: Y /N
Normal
iliK-alion: K rio\\Ieilge_J
Elimination: Incontinenl/Foley/Suprapubic Catheter
Urine Character: Dilute/Tea Colored/Amber/Hematuria/
Cloudy/Sediment/Mucous/Concentrated/Foul Smelling
I ntake * Output
Other Considerations: Ostomy Stoma Color
Assess Understanding: Returns
Demonstration/Fxplaii^J ion^
Discharge Planning:(lI ome)
Consults- Follnw-un Dr Appojntment
Discharge Teaching^Medication/Follow Up Appointments)
\1 I
Abnorjyal ^
Assess Understanding^eeds ReinforcementyjRequires More
Teaching
Discharge Planning: Rehab/SNF/I .TAC/I losnice/Mortiiarv
Consults- PT/OT/ST/Dietary/Home Health/)lospice
Discharge Teaching: Wound(jare/Tube reeding/Home 02
PlCC/Foley/Special Considerations?
^ patnopnysiojo i^ontepti v i u p
Choose l&icaldiagnoslllor patient problem related to your patient assessment or database. Determine the^auses of the medical dia^^osi^or patient
pr o bE Determine t h e Ws f f l i ^ ^ r ^' ^ T^Tn^TTTT^^^^T?^?;^^ that are caused by the medical diagnosis or
patient problem. In a concept map format develop a flow chart connecting each element.
Pathophysiolo^ Concept Map
i^MxA Cell -Uri^Hc^
f^iloirt?//Wp/r/rWi/-
Medication. 5bLU "McJivoi edication: L a ^ r X '
Classification: C<rr f- f c O'S^-er r 1
Classification: (j^vj^w
Nursing Considerations: Nursing Considerations:
Indications: Contraindications: Indications: Contraindications:
Side Effects: ^ Patient Education: Side Effects: Patient Education:
K \ (Y\ ^A r cn PI T nr \
Wh y is this Patient getting this med? Post Administration Reevaluation
Needed?
Wh y is this Patient getting this med? Post Administration Reevaluation
Needed?
Medication: ftUrrjc:! Medication: L<5Ufe>1C5X
Classification: OHpiH (\ \ (i^\ lC Classification: ^\i\V\('X)C^C\\}\<\n\ rS
Nursing Considerations: \ i
Nursing Considerations:
Indications: * Contraindications: Indications: Contraindications:
Side Effects: Patient Education: Side Effects: Patient Education:
Wh y is this Patient getting this med? Post Administration Reevaluation
Needed?
Wh y is this' Patient getting this med? Post Administration Reevaluation
Needed? , 1i >
Medication: Po"Kf=eium Chitv^rdU. Medication: \^^rS<^or ( fAPTd^ ft^W-i )
Classification: hAi'i\ .\ rA 1t^UcJnicA^k. ^piac-eW^f Classification: '^J^c\ '
Nursing Considerations: , Nursing Considerations: , ^ 1. ^1 ,
<f;/^ He4oer<^\fi{. ihUlf -fh-t^ C ^ ^ -
Indications: Contraindications:
^ t MT > ^ rer?^l Ifn^^im^nt
Indications: Contraindications:
-i^<rfji'-<'>^<=7y Cmaff^fc
Side Effects: Patient Education: Side Effects: Patient Education:
c f L<?w BP
Wh y is this Patient getting this med? Post Administration Reevaluation
Needed?
Wh y is this patient getting this med? Post Administration Reevaluation
Needed?
<l^m\ \ pr ^4 6f
/ Concept. jp Plan of Care
From your prioritized problem list on your patient database, choose the top 4 problems and develop a nursing diagnosis for each. Develop a realistic and attainable goal with the
patient and/or the patient's nurse. Perform interventions related to each diagnosis that will help the patient to achieve the goal. Upon performing each intervention, determine what
the outcome is. At the end of your clinical day evaluate your patient's progress.
Nursing Diagnosis;
Goal:
Ham^ ^{oo^ ^(^'^v' l-ei;%is
<5\n4 )<^(p ^\ji\-\i\iY\
Nursing Diagnosis;
impaired (jpfrrw
Goal: f ^ A^ i ^ V VJ^i'l ^
h O S - f i t ^ I. R^liNTv/^ m^i'eij
O: 5Vv, f l t- ^ir>- r - f f l l l J
Cr-<'cl a\)i<Jt \wr, And
Nursing Diagnosis;
Goal: -^ly^ "^ge-O.
Nursing Diagnosis;
Goal; '
Evaluation/Revision; Evaluation/Revision:
o; CeUse. tAdirfSim\^A
e a c K r m l . f^^^^
y&^^ies, W 75"'/^/:
nf her meal.
Evaluation/Revision;
fee-Is <^-*^Sft?<^heel.
E valuation/Revi si on: