Lan. Allergies/Reactions: Codeire (Rot Weed, Current Sympto COPD taoreenin lethargic (O87, od}Ugon arrival Picosts msiACC. wweson Bi connula, (OL/ mia Fics: (Last 24 he. Abnormal List here ) Lab/Diagnosti Cog hah BUN high; gecose high Penicitlins/ resckion ot listed Taw Eg GUE PMH! OBL Seskusration gon arrival | Testes: ralas\izing decdhmuanig eee ome OF UL nasal canna | Weromycio | SS RED monte Current sMober lovenox BOme loreo inhaler OO0-d'5 | pul BED nicotine eatches, dextrose ern Dressing Change: ore ‘Wounds/Incisions/Drains: CONe_ chloride leva) ereghioide las WTS Er ean Diet: Vegaior diet Jerior’ pees Pet eal ey OMEMO7; CKimal, right Foregrnn | Tata ‘Outpt [ines Fresens Quy —— pent eos ee [COD trea Bret = : no / Qa denres — |teday 15, IN Last BM: 4hqlsa Discharge/Home Care Needs: ‘ ‘Oxygen : oT Wwescaith childcen, Fal isk nosah (Prophylaxis): wont et to achete/ turns see COMA —_ on lovenex maintain eee lomosketes, loLI mic respicatecy ote /Mot| tocar ' CRERNS kises commade| Fis Hor, het canthar eck it L= ww Mescen Redagr MONROE COUNTY SLOMMUNTY COLEGE a, enriching lives DIVISION OF HEALTH SCIENCES cnc nuns / Patient's Initiale: VF age: QT. sec KA nyu 2508 Se (Code Status: Fut Medical Ox: oude on CHRONEC ChE «Diet ray ws TubeFeeding: ¢Tes/Proctves lay selecealgless ——2_Blood Sugars/Frequency: \O19 ~Wriaty fa Me s_ Respirator y Treatments/02: Wasc\ Canola UL [rain 9 ‘© _Skin Care/Dressing Changes: ——— 2180: = GBRBBOD - QO * _DVTProphalaxis: * Telemetry: WOOL Additional Notes: TODACLO use ) High Fall risk) DB eain, 2 Cire Irapic\ neat rate Causes poor & INS Be & Cee octentedt XU senildly tenpairecl vision, 5 x ¥ 3 Fz missing, teat, dyspnea as! exertion » a £5 3 88, expiratory Wheezey Siermetrical exEMsIOr, g 2 & to EIEF oceasionay I productive cough » icreguler wae § 3g a F Cordiac 1 cop rePill QOad , atrial Fibcillation é 3 g £ bl Mo) , strict T's 30's) edema io BS g 7 lower lege Pull movement ourweck, —- 2.8 bowel incontinent ;nat urinary, incomes Spas q Wile theths Uisitecd jon /oPe hedpay, ¢ & reacts Compete 2 aeslet with hygiene) no ock hes been Controlled, hock dock « ndpeq'~ we ls MONROE COUNTY ASLOMMUNITY COLEGE caviching lives ASSOCIATE DEGREE NURSING Patient Background tients nits: (a. S Age: AQ Sexi HyWe"/22 IIb) RMA BS je Status: — BSR, Comfoct cal Dx ie Isolation/Precautions: Medial Ph Hucactensue Grote OOD) = Activi “+ = Diet: Pee lar + TubeFeeding: + Te lures: ‘Blood Sugars/Frequenicy: Respiratory Treatments/02: LAL Jenin nasal eae 2 > * _ Skin Care/Dressing Changes: bey ising, amshon cledorien + 180% Tn NOS Gar * _DVTProphalaxis: Additional Notes: Fall rie, , impaicecl vision} hearin ; *rissing teath (decared), orientect x, wens! iN breath sounds diminished (, Coarse /rhonchi [usheezes)), ‘ loner entrees (+9), yt hos pocemalrer , ecch, I8/ bruising 6 i howe! rash 6p obdaren vation iia ee Wgpoachive, incontinence WSlodeaes eatin lacked; pesplee SFIS up bith Sora » WES in ASS iered bute Ceci No Social determinants Vistect exceot No Coce ince i S$ Kuta ositl 9 Frmer smoker in 105, mes hx ob cremia. yoaxleracihrilis, Gr ERD, TBs, hyPectensiveue » Had COULD hes i+ long erry Skill shedding virus wsYecan Physical Assessment: Day 1& Day2 Packers Make notes in red for day 2 of any changes from previous assessment. a Highlight the significant/relevant information for patient. (8e prepared to discuss its clinical significance with instructor*). Monroe County Community College Physical Assessment Clinical Documentation ri RAO ae EA : ‘Temperature: 42,1 Location: Axillary Rectal Tympanic (Circle One) [ Pulse: 81 Respiratory Rate: \ Pulse Oximeter: 43 02: GED) 7 NS Ne Blood Pressure: IS/U@ Location: Rt. Arm (itTArm) Rt. Leg Lt. Leg (Circle One) Position: Lying Standing Gitting) (circle One) Pain Level: (0-10.scale) 7 Lotation: bac /both Tolerable fi{JNot Tolerable ~! 5 Description: “Pt. States” : . . * coe 5 Sg p Poi sillous loellod bec cola it enters sclliag, = fa Wa Ori iented to : f Affect/Mood: Alert 0 Flat Affect © OTearful 0 Confused a O) |_Goother expan ‘Communication/Speech : WNL © Non-Verbal O Aphasia O Expressive 1 Slurred Speech J O_Other:(Explain) ee a L Pupils: PERRLA —_Pupil Size (Right) Pupil Size (Left), Equal: i] Yes (1 No(if'No) Describe: Reactive to Light: ‘Pres No Reaction: Gu Sluggish (Circle) OR Oth Pupils Round: ves O No ‘Accommodation: BR : & Lt. (Hold finger 4” above nose, bring closer to face, do both eyes maintain focus?) L rn Facial Symmetry: Wires © No (ifno, please desribe) } yf scale: 5) *(See separate sheet to determine score) | wmXK -tt Meo teens. Prodkges enriching lives DIVSION OF HEALTH SCIENCES / ASSOCIATE DEGREE NURSING Patient Background Patient's initials: GP Age: KQ sex: A Hwe5'b"/Qa7] AM: 349 Medical Dx: : ae ce hero a ‘Blood Sugars/Frequency:_N)| Dr «Respirator y Treatments/O2: NO |. 9 ‘* _ Skin Care/Dressing Changes:_\) J 1&0; : Bi Fropholns oe bapeici * Telemet a soins Sbdomical gain, once aneaky (RUG) cpa nme Qenealized Pain thet: preeatan ATM or oe s has nausta- Ealo Sho. InestoryoF coloncesaction ia DOI. hx & hy Nos agredy WWEECtension, O enc Slee, hygoer Widerig Severe Cbesity Sealy Celive/ maceied USES Qlasses \pioe veel dcemor} BD jhemia repair GOOO » moni dad ) > sere Ore loreting alive. no wedarlence 7+ was otday F See LSE i ke TON: ¢ Dialga “Cea Ae oS eae ot s+ rersiog dioggcees LOOK ATALL OF YOUR DATA- WHAT IS RELEVENT? * What signs and symptoms and relevent data is driving your nursing problems? © CLUSTER THIS DATA, WHAT ARE THE UNDERLYING THEMES ° FORMULATE YOUR Nursing problems based off of this data * Show thought, oss below... ) Acude Rain as eee %y oladowern) Bsted cain at a 8 nor herons Crest admitted inRUQ Stated pai tones 2 aps) hos bsen happen Cor (eweek’s GIVEN MOINS, Mlexeril, oniPiehics Geordoy” te © oF AOD stattag eaio is ob D Olodinn’ Uscit Aud Porection, 3) Biak (or Ffection Nad incisions henta repair 7/84/90 Now theres intra-alodomital Huld colectioa Mac Gledanvoat pall oush Eluid Genemicy te be aoe owt *e lab XN ontibicte Cosy, Cugmaniin ) 0 Far ate cemnaoacl incon Cree ; Peadioess For Enhanvedl noe aS) eenaens ee We hos a Udersteltg, the previous Shag hy has Fac Teds ki Bory understenalitigs his, limitations j not KOHNg Wc @ phe importance 6& tacreasing his activ nae to-day FOL has been cnntaslachng, Dele oom King lees Ce Ques ay, / around hye Wor \% nS yok oe Mae aa Vary forage ede end ony, bene ee UE hind eect