Answered step-by-stepHi can you fill this from with this cas
Answered step-by-stepHi can you fill this from with this case by NANDA SYSTEM PATIENT… Hi can you fill this from with this case by NANDA Image transcription textOf Visit: Jan.M. .Alangari. Time of Response: NEUROLOGY – Libby wheel .. . . . .. . . ……. D.R.. AHMAD.ALTHOBAIT!(. .:.966500586421.) will jun deal . . . . ………… Object of Consultation : Respected doctor. patient.is.6.2.years old medically. free. admitted as. case of.?. .syncope. for.investigation.. patient. complai… Show moreSYSTEM PATIENT FINDINGNEUROLOGIC LOC ?Oriented ?Alert ?Lethargic ?Sedated ?Unresponsive ?Respond only to pain ?Agitated ?Calm ?Confused GCS Motor……… +Verbal…….. +Eye……… =HEAD AND FACE Face: Facial expression, ___________? Symmetrical ? AsymmetricalNeck: ? Symmetrical ? Asymmetrical ? Presence of lumps ? Normal ? Weak ? Bounding SKIN Hair ?Thick ?Thin ?Dull ?Shiny Color………..Nail ?Flat ?Curve ?Convex ?Clean ? Dirty ?brittle Color _________________Skin Integrity ?Intact ?Dry ? Moist ?Wound ?UlcerSkin Color ?Pink/WML ? Pale ?Jaundiced ?Cyanotic Skin Temperature ?Warm ? Hot ? Cold Wound/Ulcer ?None ?Yes Location ___________________Size________________Border ___________Depth________________ Stage ______________CARDIAC/ CIRCULATORY Edema ?None ? Yes +1 / +2 / +3 / +4 Location _______Capillary Refill ?Normal (1-2 seconds) ? Delayed (>3 seconds)Arterial Pulses ?Strong ?Weak ?Increased ?Bounding ?AbsentRhythm ?Regular ? Irregular Other ____________________________________RESPIRATORY Breath Sound ?Clear ?Crackles ?Wheezes Cough ?Absent ? Productive ? Non productive Sputum/Secretion Color___________ Consistency __________ ?Thin ?ThickO2 Therapy None____ O2 @____LPM via _______________ FIO2____% GASTROINTESTINAL Diet ?NPO ? Reg ?Clear ?Soft Appetite ?Good ?Fair ?Poor ?Nausea ?Vomiting Abdomen ?Soft ?Firm ?DistendedBowel Sounds ?Active ?Hyperactive ?Hypoactive ?AbsentStool ?None ?Formed ?Soft ? Liquid Color__________ Last BM __/__/__ Other ____________________GENITOURINARY Urine ?Continent ? Incontinent ? Foley Color _____________Voiding ? with difficulty ? without difficulty MUSCLOSKELETAL ROM ?Full Limited Abnormality ?Absent ?Present Location……….ACTIVITY Activity ?Dependent ? Independent ? Bedrest Hygiene ?Clean ? Dirty SAFETY Patient Safety Needs ?Call bell in reach ? Bed in low position ? Breaks on ?Siderails up ? ID Band on Others _________________________________ISOLATION Isolation Precaution ?Standard ? Contact ? Airborne ? Droplet LINES Invasive Lines Type Size Site Condition PRIORITY NURSING PROBLEMS ( 1 Mark) ___________________________________________________________________________________________________________________________________________________________________________________________________NURSING PROCESS 1 ( ACTUAL ) ( 5 Marks) Student Marks MarksAssessment : Subjective data: Objective data: Nursing diagnosis Plan / Goal Interventions ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Evaluation Total Marks NURSING PROCESS 2 ( POTENTIAL ) ( 5 Marks) Student Marks MarksAssessment : Subjective data: Objective data: Nursing diagnosis Plan / Goal Interventions ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Evaluation Total Marks PROCEDURES DONE TODAY( 1 Mark) Rationale / Purpose A – Medical B – Nursing Procedures Health ScienceScienceNursingNURSING 317Share
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