Rhode Island College NUR 241 Patient Assessment Paper

Rhode Island College NUR 241 Patient Assessment Paper ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Rhode Island College NUR 241 Patient Assessment Paper Please see the Patient Assessment template and example in Canvas for information on what needs to be charted each week. Rhode Island College NUR 241 Patient Assessment Paper If there is missing information in the case study you can find that information in your textbook, or add in your own. Such as past medical history or subjective data. Regarding the head to toe physical assessment, you must complete each section. If you are not given that information in the case study then you can find it in your textbook. For example, when completing the neurological assessment if there is no mention in the case study of mental status then document the normal neurological assessment from your textbook and document that. Attached is an example Pages don’t matter, as long as the whole template is fil attachment_1 attachment_2 attachment_3 attachment_4 NUR 241 Medical/Surgical Clinical Patient Assessment Example of Patient Charting Use the information in the chart below as an example of how you will chart on your simulation patient in clinical. You will be required to expand on more information than what is provided, this is only an example. Input your responses and save in a word document then upload to the appropriate section in your assignments by the due date designated by your clinical instructor. Student: Date of Care_____________ Pt. Initials________Age_________Gender________Religion_____________ Code Status____________ Diet: ________Ht: _________ Wt: ___________ Primary RN: ____________CNA: _____________ Reason for Hospitalization/Diagnosis: Date of Admission: Allergies: Precautions: ER report: Pertinent/current issues: Nursing Report Off: To Do List: Time: 1. 2. 3. 4. 5. PMH: Past Surgeries: Subjective Assessment: Vital Signs: Time: Time: Temp: Temp: HR: HR: BP: BP: Resp: Resp: O 2 : O2: Explanation of abnormal vitals: Pain: Pain: Pain assessment details (characteristics and location): Medication for pain: Pain Re-assessment: IV Access: IV Fluid: Intake: Output: Total: I/O (last 24 hours): Admission wt. Today’s wt. NEURO/Musculoskeletal: Name Date DOB Place President Condition Speech PERRLA: Grasp: Gait: Recommendations: Skin: Activity Level: Restrictions: ROM: Assistive Devices: Recommendations: CARDIAC: Rate/Rhythm: Heart Sounds: Pulses: Orthostatic BP: Edema: Other: Recommendations: RESPIRATORY: O2 sats: Oxygen: Lung sounds: Cough: Resp treatment: Effectiveness: Recommendations: Tele Strip: Rhythm Interpretation Recommendations: Pertinent Diagnostic Tests and Findings GI: Bowel sounds: Abdomen: Last BM: Diet: Recommendations: GU: Urine: Catheter size and Balloon (cc): Recommendations: Social / Self-care / psych ETOH: Smoking: Drugs: Med compliance: Herbs: Stressors: Family: Status Prior to Admission: Physical; Psych/Social; Functional Status/Self-care Current Status: Physical; Psychosocial; Functional/Self-care: Patient Teaching and Discharge Planning Needs: (include community and financial resources): 2 Nursing Diagnoses and 2 possible interventions with rationales: (Prioritize) 1. 2. Labs: Today Previous Rationale for Abnormal Labs and Trend Rationale for abnormal labs (WHY are they abnormal? What process is causing them to be abnormal?): Na K Cl CO2 BUN Creat Glu WBC RBC HGB HCT PLT ADD ADDITIONAL PERTINENT LAB VALUES FOR PATIENTS SUCH AS: COAGS, CARDIAC LABS, BNP, TROPINON, HgbAIC, AND ANY OTHERS Medication List: This should include ALL medications your patient is currently taking. (Attach additional sheets if necessary) Medication Name and Classification Dose/Route/Time Due Reason for Administration (Why is YOUR patient on this medication?) Follow Up Required (What do you need to monitor when giving it?) Common and Life-threatening side affects Updated 1/28/2020 Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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