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Clinical Packet 7
Fundamentals (NUR155)
Galen College of Nursing
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MedsurgPreview text
FUNDAMENTALS ASSESSMENTS
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FUNDAMNTALSISBARR
!DENTIFICATION:(PatientDemographics)
Dolt):, L J:Jl[ Tlni<':10~
RoomU 5D'3 Age: lplp
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Weight: 1 ~Q Height:?N·u,if'\
Physician: i?eldi() Nurse: HtldL
FamilyotJct: NIA --~-~~- I lArlvn1tCt''d
Olrct:Llvc ~/A
Aid: ~IA
SITUATION: (Patient's currentstatus)
DateofAd-;i,lssion;5I1-4 Ad111lt1cd
From:C1ro '5-IYO R<''I·med Cle.
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ar,to 1 AdmittingDiagnosis: N:~~.TF N Temporal [ ·1 Oral LJTymp;mlc _BACKGROUND: (Patient's history relevant to current care needs).p\acedsu..rrac )C\r-tratuv'l ~(\owe.,(c.·<v 1..-t.fay) t/ Status:~FullCode rJDNR l ]Elopement I 1Other:_____ VitalSigns:B/P:}3jl-=l-2HR: \ \ l RR: \tp Sp02:Cli1/. ~Room Air f l 02 nt___I vlil Te - ffi--"\ - -
Allergies: [J La
ex (Xj Other:_nL'lt?-z,!Jw1' o{ -f'OJe.[ l Nl<DA PastMedical/Surgicalna-f-t 0 -f History:_Gr_gfeS6 ,o1,~~~_diGr., 6ERD ):-.Ll.I\e5>USC)e. ~~ s " '2..-ks vY\C ll\1μs I Mo_tbld~~:~@e-
o ftC.$.S--'P..\ orlC. cou-\·• Isolation Precautions: X Stand~rd _oc-_01r1 l I Contact: - -- Safety PreccJutions: L I Aspiration ixJFall I 1Seizures []Other:
- ffi--"\ - -
Allergies: [J La
Addition aISfetyconcerns/interventions: t-d) A
Assistive Devices. L J None I J Walker[Xl
Cane f ] Wheelchair
L-IOther: 1:YJ:--P-Dd CC11l----------
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I 1 Denures: (wloctone)I JUpporI ]low,,, II001h NIA
lDLAssist: -:+e5·;. Hygiene: 0D/. _
Nutrition: o·;.
:aiz-won ~ 1.Ac. \s--.. r:
Thdndefrt
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an,~ &#039;\igte."e..
l\SStSSMf:NTS: (Btlofrovlcw of body svstoms)
flu I row, l'><iillU ,,,o,,
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-- 1 l Pocl'makCI' I I Other: "1/ A
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------- t>4 Brief r IFoleyCJthotr I I Purowlcl<
Cl Independent !X1OSC l !Condon,
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Skin
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u.)arm o\ry '*'·lll-- S1r9ilA , fll \5tov1 OY1 \bl r
1
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Tubes/Lincs/Dra Ins/Drcssl ngs
None RECOMMENDATION: (Next Steps, areas of followup, open orders,tlli&Ns.fl..Qt write n1edlcalorders)
- J J '
Tubes/Lincs/Dra Ins/Drcssl ngs
Outstanding Orders:
o DrC\cJ? ou-&lt;s-cu'ld i&#039;19•
Fallow up Items:?O.\n \ e,'I e,\ 2-fi O ,i 11 RUE; l r, 10 &quot;i-1-Dy pa,I'{) k, I/d J tafr.?r et,. -
fv')()Y\ -+tr s\s nypo J 'A'JY ~ ce\ ~ , ITT OM exce,\s ~ 9'~ , • .• , ~
Clinical Concerns: in Mnn.qe.\mf- R_D~ "if\ UE',LLE"lRxhei1+- re.
iO l-eav-e rooM -Par cJrn1/\9 o. Ae-hl/11/-
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READ BACK= (Verify understanding)
Student Nurse: )u:::>\U 6N.
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Signature/Date/Time:_ /LUyG ~
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GALENt=tJNOAMENT
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NEUROLOGICAL ASSESSMENT
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- Comments: IJIU~CULOSKELETAL ASSESSMENT
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ASSESSMENT
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GENITOURINARY ASSESSMENT
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MEDICATIONASSESSMENT
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CARE PLAN
SoloctTypo: J;4,oblemFocusedrin1skNurslnoDIJgnoslI Ill'i!lthPromotion -
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Student Nornl':[rin~~!1.1 - Doto;_gPt, (Q!.Q ModlcolDloanosls· 11- _o-(
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- Subffictlve:
NANDA
Nursing
Diagnosis
Whatthep
lttnt JJrt NANOApprev,'tl (h t tu~in. Nur11n9 <11J8ntM Patient Goal \ha!ilo&#039;J topw,tl1:\1thrr~,•ofr,11r ~IICl<t 1 ShorJ-term _goal. Patientwlll:Am'ou\«&quot;e+o ~1c\e... e,crnmode OJWII, rw·). 1oi leliflOt._sdf. \ ra m n care. C(.!({c t
- Subffictlve:
NANDA
Nursing
Diagnosis
Whatthep
- j'() O~lri~ RJT: As cxhlbilcd by: SYlMdel'." p,obl«m? Wh~t CilUJl!d1•,-01the,.,. USG, ,... .,.. o-f.....+r·1 t'"\ ...1.'1.,,_,,\s--
- tfcan·fri mi-
w,r:un 1..,..1,G'-A,u n":>J nlft1,1ll 'CctrtlJM "01!.t' LIii i J I ',,.,,,\ ll'"l'mMt By: \Vl~~ U) $ dJt, I • '(r,, 1• c\ccrea-end of s\t)i+t - mo-lNa-non
Obiective: AsevidPnced Lo'l9.:!erm goal:
Mmur (ta vs. b--- - I fatlent wlff·
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;i ~•doyouknowJ IftMhJ\ai'+o td1 \e,t problem.d1t leave Y"ObfYlO (Sub/P("IJ1,-t/01" , pct(ipQte j() clara from co•urnnI Asexhibited br 0 . th th~ I''- "'r L,· d e ifteSS1ons. 011'11"iC1agnom VJ{, U-t -or,... Po CoJ) - 5S it-- uri?Knni, indcpe,rtJen+Jy
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Clinical Packet 7
Course: Fundamentals (NUR155)
University: Galen College of Nursing
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