NURS 2645L Professional Nursing 1 WEEKLY WORKSHEET sTuDENT NAME Bwké Ma: aan DATE OF CAREAZ3{\PaTIENT inrmiats Ce DNR STATUS full (Wide SAFETY CONCERNS) ALLERGIES Lae, fm | Cillins DIET (Type/Assistance needed) Cequlanith _ INTAKE [201 OUTPUT yn MBKFTI.25% LUNCH(-25% ACTIVITY ORDER YOY # OF ASSIST jmipimal acck+/ANY DEVICES. IV's, pV JuTemPAQ.Lp Pulse G@_ Resp _lly Pain Rating_10 TEACHING REEDS Tdentity and’state Reason (Cultural, Spiritual, Sexual, Psychosocial, Knowledge Deficit) PRIMARY MEDICAL DIAGNOSIS: *HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS DVT nveral with {nombuphigoty err ETIOLOGY/PATHOPHYSIOLOGY Enology “The comse of DVT is verwus stasis whiun cum be asa result of a contall von Oosrmcnen, Iimnwloilihy, Corran meclicertions avid gemeric factor Pregra pans Factor oF DVT, wien twis pr hes hed a history oF Di ‘ Coun CAG pe acu se ov OUT mt tery oF DVT unig Bo eae ie Ratwaprsiciayy Three, rnin pieces oP tve patrophysiolayy oF Ore venus Stasis, athvahen oF werk crugahn, ave vein damage, Sorverwing, cial bt blaveary oF Son yonus blued Pw, Duricg tins slaw ov dosireted Fu .a piood clot “trwmleusy firms witch Cuanes 0 DVT 40 ocr. ALL SIGNS/SYMPTOMS OF DIAGNOSIS 5S gyis and Symptoms o& OvT include “ edernay sweating GeTOLRRRLEAN Leg) (pa NOLEN (ORHAN TYE Cale ore), 4 discolavel Seinionshnelte@ (GRETA. Sore 54s anal symptoms oF a DVT in tue upper extrem Include “neck pain Siwidew pain, Swellivtain arn or haw rcyamasis, petin intr own, ANd weaeness in te hod is CAUSE OR EFFECT ON PATIENT'S PRESENT CONDITION. This DVT has caused tir pro lore her Imdbilly * dependence to perform pDLs and amioulate. She is bedndden in €demnargn LUCY wr othremniy. THKS DVT hws alco Ciudted. her lose her megnarnad dung tisk mnetter-Lt nas also greatly orate her mental WANK 0s Ste \uus ful fo be CLvUag rem bev Your Kids | SECONDARY MEDICAL DIAGNOSIS: IST ALL ON BACK OF PAGE. Qe purrent DVT ler? lower evtrenti ms! rhe SABE ey Scanned with CamScanner tyINCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O2 How Often Times, Rationale unbil He prevent Sein oreakdoum Ord ulcers on heels a Hy minimize Chance oF pressure injun4 lon tme sand region ly ume Sein 4) prevent skin breatcdaen land press we ul eas yi haw veeraunadee | Hp transeer won 40 dierent parts tu HarnieN’. Reroind hte bavn = Doug +» pruwerit prreasvave injury itn assistance [to maintain patent sat assshig te © He gecue ail ieee poe) Sa vital signs por wait Ho meitor heart ate and AR ty desevmme touting hearing, conclovulrwenan fanction nitrate tunenyy lto prmwte adequelte 0 +0 keep the jon in heathay, Carninci if general dick PE does not name arnuy dict restrictions now al ca diet doesn't affect this Spee frc med Scanned with CamScannery HEAD TO TOE ASSESSMENT DATA a Pee HIGHLIGHT ABNORMAL DATA, inc or races present: eI ea ee vier ct Te PeReLA conch ole ins pases \essy wit “tym mene natel macesa eee eee et rie “ Scanned with CamScanner(IF HIGHLIGHTED ON PREVIOUS PAGE, MUST BE EXPLAINED HERE) NEURO/MENTAL Pahoot {sn paid in LUE dl tte DVT. Eyplained da deal jn Pua icuntick Schon, CARDIOVASCULAR, Scanned with CamScannerP 4 Katz Index of Independence in Activities of Daily Living, jactivimies INDEPENDENCE: DEPENDENCE: POINTS (1 OR 0) (a Poin) (0 POINTS) JparHinc thes self completely (0 POINTS) Needs help with Jor needs help in bathing only a__pathing more than one part of the ingle part of the body such as the Jbody, getting in or out of the tub [PRESSING {1 POINT) Gets clothes from "ao help with. [closets and drawers and puts on dressing self or needs to be Jothes and outer garments -ompletely dressed. [TOILETING (1 POINT) Goes to toilet, gets on eons help transferring! land off, arranges clothes, cleans _ to the toilet, cleaning self or uses keenital area without help. lbedpan or commode. |TRANSFERRING ja POINT) Moves in and out of bed/ \Nepds help in moving for chair unassisted. Mechanical from bed to chair or requires a ksansfercing aides are acceptable. omplete transfer. |CONTINENCE pea ‘complete self (0 POINTS) Is partially or totally control over urination and incontinent of bowel or bladder. ion. FEEDING (puna Set? food from plate (0 POINTS) Needs partial or total Into mouth without help. lhelp with feeding or requires Preparation of food maybe done parenteral feeding. —— High (patient independent) 0 = Low (patient very dependent) Scant ined with CamScanner‘Problems with Eating or Feeding ‘ Tncontinence : high fal ask dj DVT Scanned with CamScannerdeveloping a pressure ulcer. A DEN SC/ - PRES: ULCER RISK- As: fi BaGo ° e © BENCERTON | Completely Limited: Very Limited: Slightly Limited: Ability ‘0 respond Unresponsive (does not Responds only to painful | Responsive to verbal sponds to verbal spor ‘moan, flinch, or grasp) to. stimuli. Cannot commands but cannot commands. Has nO Meaningfully to painful stimuli, due to communicate discomfort | always communicate sensory deficit which Pressure-related diminished level of ‘except by moaning or discomfort or need to be | would limit ability to discomfort ‘consciousness or sedation, | restlessness, ‘tumed, feel or voice pain or OR OR or discomfort. limited ability to fee! pain | has a sensory impainment | has @ sensory impairment ‘over most ofthe body which limits the ably to. | which limits ably to feel surface feel pain or dscomfort | pain or discomtorin tor aver 40 the body Bestremites. MOISTURE Constantly Moist: Moist: Occasionally Moist: ‘Rarely Moist! Degree towhich | Skinis kept moist almost | Skinis often but not Skin's occasionaly moist, | Skinis usualy ey; sskin is exposed to | Constantly by perspiration, | always moist. Linen must. | requiring an extralinen | linen requires See Utne, etc. Dampness is | be changed atleast once | change approximately | changing only at detected everytime patients | a shit once a day routine intervals moved ortumed ACTIVITY (petase Chairfast: Walks Occasionally: | Walks Frequently: Degrealf physical bed Abily to walk severely | Waks occasionally during | Walks outside the ecivity limited to nonexistent. | day but for very short | room at least twice a Cannot bear awn weight | cistances, wth or {tay and inside room andlor must be assisted | assistance, Spends atleast once every 2 into chal or wheetchair. | majorly ofeach shin in| hours during walking bed or chai, hours. MOBILITY Completely immobile: Very Limited: Stig Lied No Limitations: Ability fo change | Doesnot make even sight | Makes occasional sight | Makes Fequent though | Makes major and fand control boy | changes in body or extremity | change in body ot slight changes in body or | frequent changes in eakin Position witout assistance. | extremity positon but__| extremity poston position without table 1 make frequent or | independent assistance, significant changes independent NUTRITION Nery Poor, Probably Inadequate: | Adequate Excellent: Usual food intake | Never eats a complete meal, | Rarely eats acomplete | Eats overhalf of meals. | Eats most of every pattern Rarely eats more than 1/3 of | meal and generaly eats | Eats atotalof servings | meal. Usually ets a any f00d offered. Eats 2. | only about of any food | of protein (meat, dary | total of4 or more Servings orless of protein | offered Protein intake | products) each day. servings of meat {@meat or dairy products) per | includes 3 servings of | Occasional wil refuse a | and dary products Say, Takes fuids poory.” | meat or dary products per | meal, but wil usvally take | Occasionally eats Does not take a uid dietary | day. Occasional wil ake | a supplement offered, — | between meals supplement, a cetary supplement, OR Does not require oR OR Is on. tube feeding or | supplementation 1s NPO andior maintained on | Receives less than TPN regimen, which Clear iquids orVs for more | optimum amount o uid | probably meets most of than 5 days det or tube feeding hutronal needs. j : FRICTION AND | Problem: ‘Potential Probiem?, No Apparent Problem: | Total Points: SHEAR. Requires moderate to Moves feebly or requires | Moves in bed and in chair maximum assistance in| minimum assistance. _| independent and nas ‘moving. Complete lifting _| During a move skin sufelent muscle strength ‘without sling against sheets | probably sides to some | to lit up completely during is impossible. Feary extent against the sheets, | move. Maintains good Clinical slides down in bed or chair, | chair, restraints, or other | | postion in bed or char at requiring frequent devices. Maintains all times. Judgment Teposiioning with maximum | relatvely god postion in assistance. Spasticity, chair or bed most of the 15) ‘contractures, oF agitation | time but occasionally leads to almost constant slides down. friction. Scanned with CamScanner. RISK FACTOR | riskromts | SCORE |Confusion/Disorientation/Impulsivity_ 4 0 Fenn 7 0 tered Elimination ; A Ir oa 0 Dizziness/Vertigo 1 0 a (Gender (Male) ‘ amen 0) Any Administered Antiepileptics (anticonvulsants): z | sean ik tats Rats rcs Poa eo ba 3 0 Bae Tao [Get-Up-and-Go Test: “Rising from a Chait” eit snr ngs cyl a thr it oir thon prt hr wh ie nd Ability t0 rise in single movement - No loss of balance with steps 0 bed bownd ee Pushes up sucesulin oe ater as 1 feed town ossass Multiple atemtsbutsuccessl 3 [bed boul | Unable to rise without assistance during test Slee tunable tases document onthe patent char wih the date and ne (A score ofS or greater = High Rsk) TOTALSCORE] () eee capepced cadens etnaeteniiwaein deeds Scanned with CamScannerScanned with CamScanner