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):
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
