nursing process worksheet

please fill this out with the date march 6 and information as from march 6th instead. does not have to be crazy detailed but use info from this case study https://www.studocu.com/en-us/u/24489887?sid=01711…

Room Patient/Age/Sex Attending & consults Admit date Allergies Primary diagnoses Isolation & organisms Code status Past medical history CC/HPI Past surgical history Neuro/Psychosocial Primary language LOC/Orientation Reflexes Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____ Bonding/support Psychosocial concerns Cardiac Color Cap refill Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____ Edema & grading Respiratory Lung sounds & WOB Supplemental O2: _____ @ _____ LPM Specialty: Obstetrics OB history GTPAL EGA Blood type/Rh GBS Hep B HIV Rubella RPR Chlamydia Gonorrhea HSV Delivery summary Delivery type Delivery time Lacerations/episiotomy QBL Hemorrhage medications APGAR 1-min _____ 5-min _____ Fetal Heart Rate (FHR) tracing Heart rate Variability Accelerations Decelerations Category GI/GU Diet IV fluids Last BM & character Bowel sounds Able to void/catheter present Urine output & character Contractions Frequency Duration Musculoskeletal & Safety/Mobility Activity ROM Additional Labs BUBBLE assessment Breasts Baby notes Last feed Uterus Breastfeed/formula Bowel Last void Bladder Last bowel movement Lochia/Episiotomy/Incision Emotional Diagnostics/Imaging Lines 1 2 3 4 5 6 7 8 OTOs/PRNs given & time last given Continuous IV Drips 1 2 3 4 5 6 7 8 To-do/Follow-up/Notes Shift Notes 07/19 Vitals 08/20 09/21 08/20 12/00 16/04 10/22 Temp & source HR & rhythm 11/23 12/00 13/01 14/02 BP & MAP Resp rate 15/03 16/04 17/05 18/06 SpO2 & delivery method Pain & pain scale used Medication Administration Record – provide 5 most critical/priority medications Generic & trade name Pharm class Dose Route Freq Indication(s) r/t patient Common SEs/ADEs (at least 3) Nursing considerations (at least 3) Plan of Care (Clinical Judgment Plan) Priority problem #1 [hypothesis]: Priority problem #2 [hypothesis]: Priority problem #3 [hypothesis]: Pertinent assessment data [cues]: Pertinent assessment data [cues]: Pertinent assessment data [cues]: S.M.A.R.T. goal/outcome #1 [solution]: S.M.A.R.T. goal/outcome #2 [solution]: S.M.A.R.T. goal/outcome #3 [solution]: Interventions with frequency & rationale [actions]: Assess/monitor: Interventions with frequency & rationale [actions]: Assess/monitor: Interventions with frequency & rationale [actions]: Assess/monitor: Manage: Manage: Manage: Educate: Educate: Educate: Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):