=e Yo 7 NURS 26451 Professional Nursing 1 Mao dels! Cotngepy "ard py, WEEKLY WORKSHEET. $<) ivy pq stupent name Chas Ley pate or care2/2 _parientinmiats & & DNR status £1! Cede SAFETY CONCERNS_ “t= AmbAtem — altercies_ VA DIET (Type/Assistance needed) Gene-a | INTAKE ouTPUuT BKFT Jeo % LUNC! ACTIVITY ORDER_F! West beomygtt OF ASSIST. ANY DEVICES__f/e7 = Vs Bp” “oyrempAF-2 Pulse Zo Resp_/G Pain Rating 2//2 477] TEACHING NEEDS — Identify and State Reason (Cultural, Spiritual, Sexual, Psychosos nowledge Deficit) Etphininy mpetay 9 omit F/6 aad air: qasers PRIMARY MEDICAL DIAGNOSIS: *HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS ETIOLOGY/PATHOPHYSIOLOGY Benya Pre44s hyperplasia (BPH) (9 69 enlrgel Prick. Tt occurs 9 malo as bey asa. fis te Proshh €nlzeg 14 pts Preame nthe urethra whith ton ble inte Clone, Mat mm base Cobined Prokhe glk Homelae Ber UG. Urteted, BPH an Carta Kidey henge, Uf2a, bihey PO, ard bho danege Te vin entoely Clem het Cente, the prose %erhy, | PH may & duc 40 Set herame Ching, 95 men Seow olla ALL SIGNS/SYMPTOMS OF DIAGNOSIS. Stops / Syp plone sclah Cryer crite, Pvt hnin, A evalty Sctrg erasha inshilly fe Cmyplhl, mph, Aidt, and Avbbliy 96 tle Of oF He (es crinkn, 0 i Grimm a alk heraten, OT Ep aol Anbilby lo erimte. frost. Site dee nef ae « a ‘e NeCetserly E Sy 15 shy Commer. CAUSE OR EFFECT ON PATIENT'S PRESENT CONDITION. — “sie Pr rakes Lis far cs Wie hang re ise beh or \L DIAGNOSIS; LIST ALL ONIONS): INCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O2 THERAPY ‘reatment (Intervention) | How Often Times, Rationale at ke - ae | Des Psy | French Sh Trtrit, Freity Brel "pith |Paty | By | Dity tien Pract He! (dp Dety | Doty | mitre Ktey J crhey bot tr fu si pe igiel DW ing Ve FT - WE De fr | (AW | Fe & Seabt alien pos VRE 5 Ga, Secl Baty | hg | Wirt Chaz TARGET ASSESSMENT (Hospital Only) What body system(s) Orirweg Why did you choose P+ admitted! dl, PP Sto his grin is SH beth Document assessment of that system 1b Comphle 0 dull. pom > Urimtihy, and Sere 4 19 He shlos he Fels muh be PF hes had bo _ibsvey Urine ot he yeh ty UTHEAD TO TOE ASSESSMENT DATA, HIGHLIGHT ABNORMAL DATA NEURO/MENTAL fis Ab 44, flee pardon ae Shave Lege ay carviovascutar Kegvice heart rly Ay. P+ “€ Po SF. Si + Sp sched. PERIPHERAL/VaSCULAR_/Vo Coma retecl in sv Y Chtemtes Cacbid, Fede} 9nd Pedal pile, hte DE ilbally, Gp by) trde O~ Seen S35. RespiRAToRY Linys Clea anlenin, peskow 4S lethally bihbn te, Cn Chas Ae eal G1 [VI bee LAE Shetiers oO ben th. Pi is 974 i RA ap 6 95a, GASTROINTESTINAL ove! Sommly nermea nen feat, Le hermes (5ent, Nedawemferdermera"sil” [ahaa of Bele eee 6M nt 0800 with bord brow Srcl. We be Feil, Lian GENITOURINARY (Jette ame ivith no Sclinetstiey Mo pon ben wai 4 oF bm f, jhty, Welsh, skin Pe bus ©) Srekel abjiasy, fy Petoh wth 36 on wpe bce Cseetnerh faye) Vi ote erties O-line EL, hae MuscuLosKeLeTal Me Lotaben. (tt Cor tefl Wilat a155dne . Wo Un Stecdy oct psycHosociaL_Pt unk-s44 Crohn Grol PRIA all teasfrests. PAIN/DISCOMFORT.(IF HIGHLIGHTED ON PREVIOUS PAGE, MUST BE EXPLAINED HERE) NEURO/MENTAL. CARDIOVASCULAR, PERIPHERAL/VASCULAR, RESPIRATORY. GastrotestiInal Abd par doe % FY. Rake por of Vo, Genirourivary_C aia Prvetlyal Flormy. san EL Sthis rash ape) eg Epes he be anew whbohe ues ra (ttm om He a Gi (Re Lees ee ey PeKatz Index of Independence in Activities of Daily Living (CTIVITIES INDEPENDENCE: |DEPENDENCE: \ -OINTS (1 OR 0) 1 POINT) (0 POINTS) [BATHING {1 POINT) Bathes self completely (0 POINTS) Needs help with ing only a Jor needs help/in batf ingle part o' body such as the ppathing more than one part of the body, getting in or out of the tub JORESSING (1 POINT) Getsclothes from (0 POINTS) Needs help with {closets wild and puts on _|dressing self or needs to be lothes and outer garments -ompletely dressed. |TOILETING {1 POINT) Goes to toilet, gets on (0 POINTS) Needs help transferring| ~ ind off, arrang¢s cloyhes, cleans _ {to the toilet, cleaning self or uses senital area wit it help. bedpan or commode. JTRANSFERRING (1 POINT) Moyés ifr and out of bed (0 POINTS) Needs help in moving jor chair unasbist¢d. Mechanical from bed to chair or requires a ransferring siés are acceptable. [complete transfer. |CONTINENCE 1 POINT) Exevgises complete self (0 POINTS) Is partially or totally ontrol over fin and incontinent of bowel or bladder. lefecation. EEDING (0 POINTS) Needs partial or total (1 POINT) Gets food from plate linto mouth Es help. Preparation of food may be done ee with feeding or requires arenteral feeding,Fulmer SPICES: Ain Overall Assessment Tool for Older Adults Skin Breakdown Bie Se aie SPICES EVIDENCE Yes No Sleep Disorders None Problems with Eating or Feeding Nee Theontinence No sce tes S/2/79 Confusion fAfo x4 Evidence of Falls- _s2645 Assessment: Directions: Add up the total points, a perfect score is 23. A high score means lower risk for developing a pressure ulcer. A low score means higher risk BRADEN SCALE - PRESSURE ULCER RISK. Assess Prior to and during clin oe e eo o Bee eM Completely Limited: Very Limited: Slightly Limited: No Impairment: ret respond | UrESPONsive (does not Responds only to painful | Responsive to verbal Responds to verbal {| Ability fully te moan, flinch, or grasp) to ‘stimuli, Cannot commands but cannot commands-Has no meaningfully to painful stimuli, due to communicate discomfort | always communicate sensory Aeficil Which pressure-related | diminished level of except by moaning or | discomfort or need to be | would it ality to discomfort consciousness or sedation, restlessness, turned, feel or\voicg pain or OR OR oR siscomt limited abilty to fee! pain | has a sensory impairment | has a sensory Impairment ‘over most ofthe body Which imits the ability to | which imits ability to fee! ‘surface. feel pain or discomfort pain or discomfort in 1 or over % of the body. 2 extremities MOISTURE Constantly Moist: Moist: Occasionally Moist: Rarely Moist: Degree to which | Skinis kept moist almost | Skins often but not Skin is occasionally moist, | Skin is weually dry: skin is exposed to | constantly by perspiration, | always moist. Linen must | requiring an extra inen | nen eaurde Pa chie urine, etc. Dampnessis | be changed atleast once | change approximately | chandhag-nly at detected every time patientis | a shi. once a day, routine intervals moved or tumed, | ACTIVITY Bedfast: | Chairfast: Walks Occasionally: Walks Frequently: Degree of physical | Confined to bed Abily io walk severely | Walks occasionally during | Walks oytsie the activity limited to nonexistent. | day but for very short | room a Cannot bear ovn weight | distances, wih or day anktinSide room must be assisted | assistance. Spends atleast once every 2 vair or wheelchair. | majority of each shiftin | hours during walking ie ai get fae MOBILITY Completely immobile: | Slightly Limited: Ability to change | Does not make even slight | Makes frequent though ‘and control body _| changes in body or extremity slight changes in body or Position Position without assistance, | exiremity position but extremity position unable 10 make frequent or | independent significant changes independent NUTRITION Very Poor: Probably inadequate: | Adequate: Usual food intake | Never eats a complete meal, | Rarely eats a complete _| Eats over half of meals, pattem Rarely eats more than 1/3 of | meal and generally eats | Eats a total of 4 servings any food offered. Eats2 | only about % of any food _ | of protein meat, daly servings or less of protein | offered. Protein intake | products) each day, (meat or dairy products) per | includes 3 servings of | Occasionally wileluse a day. Takes fluids poorly. ‘meat or dairy products per | meal, but will usually take Does not take a liquid dietary | day. Occasionally will take | a ‘supplement if offered, supplement, a dietary supplement, OR OR OR Is ona tube feeding or Is NPO and/or maintained on | Receives less than TPN regimen, which clear liquids or IVs for more | optimum amount of liquid | probably meets most of than 5 days. diet or tube feeding, nutritional needs. FRICTION AND —_| Problem: Potential Problem: No Apparent Problem: | To! SHEAR Requires moderate to Moves feebly or requires | Moves in bed and in chair | ‘maximum assistance in ‘minimum assistance. independently ahd has | moving. Complete liting During a move skin sufficient | Jstrength without sliding against sheets | probably slides to some _ tollft up: during clini is impossible. Frequently | extent against the sheets, | move, Maier oocdiana iG) at | Jude slides down in bed or chair, | chair, restraints, or other | position in bed or requiring frequent devices. Maintains | alltimes, repositioning with maximum | relatively good position in. assistance. Spasticty, chair or bed most of the: contractures, or agitation leads to almost constantRISK FACTOR. \Confusion/Disorientation/Impulsivity oO Symptomatic Depression oO Altered Elimination oO Dizziness/Vertigo oO Gender (Male) | |Any Administered Antiepileptcs (anticonvulsants): (carbamazepine, Dvairoe Sodium, Ethotoh, Ehosuimide, Flbarate,Fosphently Gabapentin, Lametiine, Meshenton, Methsxnide,Phenabartit, Phenan, Prnidne, Topiramate, Timetadl one, Vapi Any Administered Benzodiazepines:” [Woranlam, Clolanepoide, loazesam, Cor Hataesam’ oranepam, Midazolam, Onazepo,Tas:ep pots nepali, |Get-Up-and-Go Test: “Rising from a Chair* tunable to astess, monitor fr change in act eve, sae othe ik facto, decent bth on patient chart wth date ad ne Ability to rise in single movement - No loss of balance with steps Pushes up, successful in one attempt (Multiple attempts but successful Unable to rise without assistance during test unable to assess, document this on the patient chart with the date and time, (Asscore of Sor greater = High Risk) TOTAL SCORE (©2012 Ai of ona, Al ights reserved. United Sates Patent No, 7282031 ae US, Pte No, 7/682 308, Reproduction of copyright ad patented materials without authoration it Walton federal aw, Cope aineven pte ‘avert flawed ete eer rd eh nt Mal a et ‘Gone certs tt nt ent a ee 2 2st ne a ib Bee Hs Seeds yh Z aren nen sen nt nt a Ne eeMcCaffrey Initial Pain Assessment Tool §/2ys c moe fA, SY Ce = Se Nase rome ELAPIL, 2 DOBSITY: Peau apee pan seiend Boks 72> lo - on blo Seale Present: io Wortpainges: OTR poverent Best pain ges: yy Acceptable evel ef pais: To" a 3 quatmry: SiS ae Se eee eee iS Dare 2 Pa ee setfen 5 MANRER OF EXPRESSING AT a a a Tale (6. WHAT RELIEVES THE PAIN? PF Compas Serh! absars.