Care Plan RN Progress Note Essay Assignment Paper

Poor Concentration Poor Judgment Confused Racing Thoughts Minimize Issuescare plan

Reactive Labile Fearful Anxious Sad Tearful Poor Motivation Hopeless Flat Blunted Restricted Patient Asleep Non-Verbalcare plan

Lethargic Crying Pacing Oppositional/Defiant Destroying Property Agitatedcare plan

Angry Outbursts Impulsive lntrusive Hyperactive Pressured Speech Resistive to Care Disorganized Sexually Inappropriate Verbally Aggressive Physically Aggressive Eyes closed Resting Harming Self by:

Symptoms

GU 

No Pain a Pain (1-10) NO HURT HURTS HURTSMORE EVEN HURTSMORE WHOLE HURTSLOT WORSTHURTS

Description of Pain: Dull Sharp Aching Burning Stabbing Shooting Other:

Aggravates Pain: Physical Activity D Sitting 13 Standing Walking O Other:

Effects of pain on daily-activities: Cl None Somewhat limiting Very limiting Interventions implemented«.

Medication administered within last 24 hours: Yes No

Educated patient on alternative interventions for pain management: Refused alternative options

Positioning Hot/Cold therapy Guided imagery Exercise/Stretching Deep breathing

Refocusing/Distraction Music therapy Modified environment Other:

Tests: N/A Yes

Assessment

Gl: Bowel Movement: Yes No Normal Nausea Vomiting Diarrhea Constipation

Side effects/Adverse drug reactions:

Medication teaching provided to: Patient Parent Method: Handout 1:1 Instruction

Self-Harm Assault Homicide Elopement Seizure Fall Medical Risk

Arson Sexual Victimization Sexual Aggression NONE