Bacterial Infection of the Joints and Skin Tissues Report
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atch this following clip:
Please fill out the nursing process sheet; Please use the narrator’s talk of his symptoms to answer the process sheet questions. I understand you are not going to have all the information in the clip to answer all of the questions. Where the question is not applicable, please indicate N/A; where you’re unable to assess (substance use, maybe medications, pt’s mood) please indicate UTA (unable to assess). Typed submissions only. You should have at least 1-2 nursing dxs (can be at-risk or actual). Anticipate you’re the nurse assessing/caring for this pt. You do not have to do the D-A-R portion. Thank you!
Bacterial Infection of the Joints and Skin Tissues Report
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Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1 Student Name: ___________ Date: Client History: Name (initials only):______ Age: _____ Gender: _____ Unit: _____ Date of Admission: _________________ Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): 5150 Advisement (quote): Psychiatric Diagnosis: Medical and (or) physical problems: Psychosocial and Environmental Problems: (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem Reason for hospitalization (Client’s own words): Current stressors: Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Affect (blunted, flat, guarded, labile, expansive, sad, or other): Page 1 of 6 Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 2 Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Thought Content: Suicide Ideation (plan and/or intent): Homicidal Ideation (plan and/or intent): Hallucinations (auditory, visual, olfactory, gustatory, tactile): Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): Cognition (orientation, memory recall, concentration, attention span): Bacterial Infection of the Joints and Skin Tissues Report
Insight: Judgment: Coordination/gait/notable movement: Cultural issues, familial concerns and religious affiliation that may affect his/her care: Support System: Current Physical Health: Vital Signs – T: Pain (Numeric 1-10): Page 2 of 6 P: R: Location: BP: / Pulse Oximeter reading: Character: Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 3 How would you describe your health: Nutritional Status: Diet: Excellent Average Feeding supplement: Good Poor Swallowing / Chewing difficulty: Elimination Pattern: Activity-Exercise-Sleep-Rest Pattern: Group Attendance and Level of Participation: Substance Abuse: Substance Amount / Frequency Duration Withdrawal symptoms: Other Addictions (gambling, sex, internet, shopping, internet, etc.): Discharge Plans: Potential Nursing Diagnosis (Risk / Actual): Planning (patient goals): Nursing Interventions (include patient education): Evaluation (patient response to interventions and teachings): Page 3 of 6 Last Used Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET:
Daily Charting 4 MEDICATION LIST Medication (Generic / Trade) Dose / Route / Frequency / Range Side Effects Food and Drug Interaction Purpose / Rationale for the Patient Medication (Generic / Trade) Dose / Route / Frequency / Range Side Effects Food and Drug Interaction Purpose / Rationale for the Patient Medication (Generic / Trade) Dose / Route / Frequency / Range Side Effects Food and Drug Interaction Purpose / Rationale for the Patient Medication (Generic / Trade) Dose / Route / Frequency / Range Side Effects Food and Drug Interaction Purpose / Rationale for the Patient Page 4 of 6 Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 5 Laboratory Report: LAB DEPAKOTE LITHIUM TEGRETOL DILANTIN WBC Date: Hour Page 5 of 6 Focus / Nursing Diagnosis DATE RESULTS D – Data A – Action REERENCE RANGE R – Response Course: NURS 223L PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 6 West Coast University Patient Identification Patient Care Notes Student Daily Journal Personal goals for the day: Experience and activities of the day: Thoughts about your experience today: (How did you meet your goal?) Your feelings about today: (How can you utilize your experience in the future?) Page 6 of 6 . Bacterial Infection of the Joints and Skin Tissues Report