...NURSING CARE PLAN COURSE: Basic Adult Health CLIENT INITIALS: DATE OF ADMISSION: AGE: GENDER: JL June 13, 2011 85 M HT: WT: ALLERGIES: 140 lbs. NKA CODE STATUS: FULL RACE/ETHNICITY: CULTURAL CONSIDERATIONS: Caucasian None RELIGION/SPIRITUAL CONSIDERATIONS: Unknown OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES: Retired LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc) Lives with daughter. SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics) Quit smoking many years ago, no history of ETOH or drug use. NURSING CARE PLAN ADMITTING MEDICAL DIAGNOSIS: Client's principal admitting diagnosis was leukocytosis. Definition: (from Taber’s) “An increase in the number of leukocytes (usually above 10,000/mm3) in the blood. It occurs most commonly in disease processes involving infection, inflammation, trauma, or stress, but it also can result from the use of some medications” (Venes, 2009, p. 1327). Etiology/pathophysiology: ( NOT from Taber’s or Wikipedia) Etiology: Causes of leukocytosis are infection, inflammation, tissue damage, immune reaction, bone marrow problems, medications, and stress (Drug Information Online, 2011). Pathophysiology: “Leukocytosis can be a reaction to various infectious, inflammatory, and, in certain instances, physiologic processes (eg, stress, exercise). This reaction is mediated by several molecules, which are released or regulated in response to stimulatory events that include growth or survival factors (eg, granulocyte...
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...J. A. Care Plan Tamara Parker South College Medical Dx: Depression Allergies: Demerol, Oxycodone Hx: 91 y/o female brought to Shannondale from Blount Memorial with multiple fractures which she sustained from falling out of her bed. Patient suffers from chronic back pain and has hx of osteoporosis, muscle weakness, glaucoma, hyperlipidemia, kyphoplasty with bone fusion, back fusion, stemi, OA, and depression. |Neuro: |GU: | |Alert and oriented x3. Little confusion |No bowel movement since 3/2/16. Urine x1. | | | | |EENT: |MS: | |PERRLA, normocephalic, presbyopia. |Generalized weakness, uses wheelchair, needs little assistance with ADL’s. | | ...
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...NURSING CARE PLAN # 1 Write one (1) priority NANDA nursing diagnosis for the assigned client. Address one of the following client needs in identifying the nursing diagnosis: 1. Oxygen, 2. Fluids, 3. Nutrition, 4. Urine or bowel elimination, 5. Comfort and hygiene, 6. Activity, rest & sleep, 7. Safety, and 8. Psychosocial For additional information on writing care plans see “Writing the Nursing Care Plan” in the NRS 104 Syllabus. Nursing Diagnosis (Client specific problem; Use NANDA and PES format) Client Goals (Specify 1 short-term and 1 long-term goal) 2 Nursing Interventions (To assist client in meeting expected goal) and 1 Teaching intervention Rationales for Nursing Interventions (Cite source, year, and page number of text for each rationale) Actual evaluation based on care provided during the clinical day Transfer ability impaired related to difficulty of moving from bed to bathroom and back. STG: Patient will be able to transfer from bed to the bathroom with assistant three times at the end of the shift LTG: Patient will be able to use the walker to move around in two week. Help client put on shoes or nonskid socks when transfer Apply a gait belt to lower back before transfer her. Keep the belt close to the patient when transfer - with shoes or nonskid socks will prevent from slip or fall (Ladwig 376) - The belt provides a handle of sorts, that allows whomever is escorting to weakened individual to easily grasp the...
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...Northwest Tech Community College Nursing I & II Care Plan Student's Name: Client's initials: Date: ___________ Age and Developmental Stage: 69 year old Integrity vs. despair this patient is in despair not able to care for himself financially. ______ Diagnosis and Definition: Pneumonia- infection in lungs caused by a pathogen. ______ ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬-__________________________________________________________________________________________________________________ IDENTIFIED NURSING DIAGNOSIS SHORT-TERM GOAL INTERVENTIONS NURSING ACTION TAKEN RATIONALE FOR NURSING INTERVENTION EVALUATION OF THE EFFECTIVENESS OF THE SHORT-TERM GOAL I. Health Perception/ Management A. Nursing Diagnosis: Risk for Injury Subjective: Pt states he has lost his pep and stamina. Has shortness of breath with any exertion. Objective: Pt has Rheumatoid Arthritis and uses a walker. A. The pt will not fall during my shift 1. Provide night light 2. Keep patient’s room free of clutter 3. Assist the pt with all transfers and ambulation. If the patient requires multiple pillows for rest or positioning, tape the bottom layer of pillows to prevent dislodging. 1. Safety measures to prevent falling at night (Cox,2007,p.62) 2. Basic safety measures to prevent injury (Cox, 2007, p.62) 3. Assist in preventing suffocation or tripping on pillows. (Cox,2007,p.62) Goal was met. Pt ambulated with one person assist...
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...restaurants/bars, eating outside on restaurant patios smoking and drinking alcohol. Some of these people were obese. Smoking, drinking and obesity are contributors to heart disease that could be easily modified; ethnicity cannot be modified which is a small factor in this community. Hispanics are more susceptible to diabetes and African-Americans to hypertension. These are disease processes that may lead to heart disease. Sometimes lack of knowledge and education can also contribute to these problems. Community health nursing diagnosis (Used at least one nursing diagnosis for the community). Deficient knowledge regarding condition, treatment plan, selfcare r/t unavailability of health education as evidenced by increased heart disease in community. Risk of decreased cardiac output r/t smoking, drinking and obesity. Community health nursing plan (Identified at least one short term and one long term goal for the community. The goal/objective is related to the priority problem and is a measurable statement): Short Term Goal: By 2017, 25% of people will be educated on heart disease and risk factors. They will be provided with programs to help quit smoking, diet and exercise programs and pamphlets on alcohol. Long Term Goal: By 2020, there will be a 5% decrease in heart disease for this community. Community...
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...more on the problem of dysphagia and the patient’s needs related to this particular problem. Dysphagia is a condition in which the action of swallowing is either difficult or where the swallowed material seems to be held in its passage (McFerren 2008). The assessment, planning, implementation and evaluation (A.P.I.E) of the patient on admission and discharge will be discussed in further and more precise detail throughout the essay while maintaining the dignity and respect of Mr. Smith. This health problem was chosen due to personal experience with family members who have suffered stroke as well as working with patients on practice placement, and seeing how important it is to respect the person as an individual and to give them the holistic care they deserve and allowing them what independence they have left. Finally the essay...
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...NURSING CARE PLAN ASSESSMENT Subjective: “Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient. Objective: • Statement of misinterpretati on. Request for information. V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80 DIAGNOSIS • Knowledge deficient regarding condition and self care related to information misinterpre tation. • INFERENCE Cholecystect omy is the surgical removal of the gallbladder, a small pearshaped sac that is located directly beneath the liver in the upper right side of the abdomen. The gallbladder's main function is to store bile, which is produced by the liver, and to release it as needed for digestion. The gallbladder's function is important, but it is not • PLANNING After 8 hours of nursing interventions the patient will verbalize understanding of therapeutic needs. INTERVENTION Independent: • Review disease process, surgical procedure or prognosis. • • RATIONALE Provides knowledge base on which patient can make informed choices. Promotes independence in care and reduces risk of complications. During initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats. Minimizes the risk of pancreatic involvement. Intestines require time to adjust to stimulus of continuous output of bile. Indicators of obstruction of bile flow or altered digestion, EVALUATION • After 8 hours of nursing intervention s the patient was able verbalize understandi ng of...
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...Putong, Jonathan 4 y/o Post incision and drainage Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation | Subjective:“ sakit sugat ko dito ma” as verbalized by the patientObjective: * Localized erythema and edema * (+) pruritus on the site of the incision. * (+) Facial grimace * (+)Irritability * (+) Guarding behavior * (+) Crying * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 * Pain assessment>Location: Right post auricular area>Interval: frequent | Acute pain related to tissue trauma secondary to incision and drainage as manifested by * Localized erythema and edema * Pruritus on the site of the incision * Facial grimace * Irritability * Crying * Guarding behavior * Frequent interval of pain | Nociceptive stimuli(wound/inflammation)↓Nerve fibers (nociceptor) ↓ ↓A-delta fiber C-fiber (fast) (slow) ↓ ↓ Spinal cord & Dorsal horn pain modulating circuit (primary touch...
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...Braden Scale Assessment Tool for Predicting Pressure Ulcer Risk(copyright Barbara Braden and Nancy Bergstorm, 1988) | Sensory PerceptionAbility to respond meaningfully to pressure-related discomfort | 1. Completely LimitedUnresponsive (does not moan, flinch, or grasp) to painful stimuli caused by diminished level of consciousness or sedationOr Limited ability to feel pain over most of the body. | 2. Very LimitedResponds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessnessOrHas a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body. | 3. Slightly LimitedResponds to verbal commands, but cannot always communicate discomfort of the need to be turned.OrHas some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. | 4. No ImpairmentResponds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. | MoistureDegree to which skin is exposed to moisture. | 1. Constantly moistSkin is kept moist almost constantly by perspiration, urine, etc. . . Dampness is detected every time a patient is moved or turned. | 2. Very moistSkin is often, but not always moist. Linen must be changed at least once a shift. | 3. Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day. | 4. Rarely MoistSkin is usually dry; linen only requires changing at routine intervals. | ...
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...November 17, 2012 ASSESSMENT | DIAGNOSIS | SCIENTIFIC EXPLANATION | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“hindi na siya makaramdam masyado sa kanan na bahagi ng katawan niya,” as verbalized by the SOindi naObjective: * response to stimuli: * pressure (-) * tickling (-) * pain (-) * on right side of the body * patient responds to normal tone and volume of voice but does not respond to whisper on both ears * trigeminal nerve assessment (sensory) * patient was unable to feel wisp of cotton when touched on face * decreased attention span * motor incoordination | Disturbed sensory perception related to altered sensory reception, transmission or integration secondary to injury on the temporal and parietal lobe(left hemisphere) | Chronic hypertensionorArteriovenous malformations↓Rupture of diseased blood vessel↓Formation of hematoma↓Increased pressure within the brain↓Disturbance of normal brain anatomy↓Affectation of the somatosensory area in the temporal and parietal lobe of the brain↓Disturbed sensory perception | Short Term:Within the course of therapeutic regimen, the client will be able to demonstrate techniques to compensate for altered sensory perception as evidenced by: * Turning head to see people or things * Following persons or objects by moving eyes * Scanning the room for persons or objectsLong term:With continuous therapeutic regimen, the client should be able to: * Compensate for the sensory impairments * Improve...
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...Nursing Theory Plan of Care Fintan O’Connell NUR/513 May 23, 2012 Francine McDonald Care Plan for Ronald Issler |Nursing Process |Data and Relevant Information | |1. Breathe normally |Complains of shortness of breath, oxygen saturation 88% on room air, | | |heart rate 58, chest x-ray with bilateral lower lobe infiltrates, | | |history of DVT. | |2. Eat and drink adequately |Height 6 ft., weight 147 pounds. BMI 19.7 (lower range of normal). | | |History of congestive heart failure, takes diuretic. Hemoglobin and | | |hematocrit levels low (HGB 10.4 gm/dl, HCT 29.6%) | |3. Elimination of body wastes |History of congestive heart failure (as noted above), elevated | | |creatinine level of 2.0 mg/dl | |4. Move and maintain posture |Increasing weakness...
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...Running Head: NEWBORN ASSESSMENT AND CARE PLAN Newborn Assessment and Care Plan Newborn Assessment On 1/29/09, at 0610, 39 week gestational age, 7lb 4.6oz, black male was born to 18 year old mother. Infant born via vaginal delivery with assistance of vacuum extraction, nuchal cord x1 noted. Mother received adequate prenatal care beginning at 8weeks. Prenatal medications included Iron supplements and prenatal vitamins. Prenatal complication included pregnancy induced hypertension. Onset of labor 0647, full dilation 1705, and delivery of infant at 1810. Apgar scores 6/8.Weight 3305gms, length 20 inches, head circumference 12 inches, chest circumference 12 ¾ inches, abdominal girth 12 inches. The infant is alert and active. Anterior fontanel is soft and flat. No oral lesions. Head caput/ molding, elongated with edema, abrasion noted from suction. Color is pink and changing all over (African American.) Skin is warm, dry, and well perfused. No rashes, vesicles, or other lesions noted. Birthmark present on forehead approximately 2cm. Bilirubin test ordered. Lanugo present. Hair pattern is scattered evenly all over, fine texture and moderate amount. Eyes symmetrical and in midline. No discharge present from eyes. Eyes move from left to right and sclera is white. Eyebrows are fine and symmetrical. Nose is patent and midline. Ears present symmetrically. Mouth midline. Gums and tongue pink and moist. Cheeks symmetrical with no lesions. Saliva present. Chin well aligned on face...
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...Running head: NURSING CARE PLAN II Nursing Care Plan II Maria Milazzo Cochise College Nursing 123 April 16, 2010 Maxine Parmley RN, MSN Nursing Care Plan II Setting and Demographics My scheduled clinical rotation at Life Care Center began on April 8th. Mrs. X, a long-term resident, was the patient I had chosen. I had conducted several patient interviews and she appeared to be an interesting patient. After passing out the morning medicines to the resident’s, I made my way down the hall to Mrs. X’s room. When I arrived to Mrs. X’s room she was quietly sleeping in her bed with a book titled the “Autobiography of Hilary Clinton” on her stomach. I knocked on the door and proceeded to greet her and introduce myself, she sat up, smiled, and said she loved visitors. I explained my school assignment to Mrs. X , and requested permission, and perform a physical assessment she stated, “ it was quite alright.” She is a hispanic ninety one year old woman, approximately five feet five inches tall, and weighs 98 pounds; she has been a resident of Life care for eight months. Her current diagnoses included a closed ulnar fracture with rehabilitation, atrial fibrillation, and coronary artery disease. Her secondary diagnoses are hypothyroidism, depressive disorder, hypertension, esophageal reflux, generalized pain, and chest pain. Functional Health Patterns Health Perception-Health Management: Subjective: Patient stated her general health has been declining recently, with three...
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...NORTH CAROLINA CENTRAL UNIVERSITY DEPARTMENT OF NURSING 4003 Modified Nursing Care Plan You must submit the clinical tool with the care plan Student Name : Crystal Stephenson Date: October 27, 2012 ------------------------------------------------- Patient Summary: J.M. is a 25 year old Caucasian female G1 T1 A0L1 who began Stage 1 of labor 10/21/12 at 2300. She presented at Wake Med 10/22/12 at 1655 with SROM and contractions. She received treatment for GBS after testing positive. She delivered a baby girl weighing 6lbs 6oz 10/22/12 at 2057 with the assistance of a vacuum. Baby’s AGARs were 8/9. Client received an epidural during labor. Her estimated blood loss was 400 ml. She received a 3rd degree laceration to her perineal area during labor and has not been able to void since even when she has had the urge to. An indwelling foley was placed 10/23/12 at 1230 to relieve urinary retention and bladder distension. 600 ml of urine was collected 10/23/12 at 1800. She was prescribed Dermoplast 20% to use while providing peri care to relieve the discomfort and swelling of her perineal area. Client is currently breast feeding. She received education about different feeding positions and has demonstrated a good latch with the baby in the football hold. Client is allergic to Macrobid and experiences hives and itching when exposed...
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...Nursing for Health and Wellbeing 2012 Patient Name: Jake Anderson Student Name: Linda Nguyen Student Number: 17532189 Nursing Issue: Development, risk of delayed due to poor nutrition and inefficient social interaction as evidence by Jake’s limited speech and often refuses to eat lunch. Goal/s: To promote a healthy nutritional intake and increase social interactions to prevent delayed physical and psychological development. INTERVENTION | RATIONALES FOR INTERVENTIONS | 1. Full health assessment. (Crisp & Taylor, 2010). 2. Assess ADL’s. (Holland, Jenkins, Solomon & Whittam, 2009). 3. Assess activity level. (Holland, Jenkins, Solomon & Whittam, 2009). 4. Refer to Occupational Therapist. (Crisp & Taylor, 2010). 5. Refer to dietician. (Crisp & Taylor, 2010) 6. Refer to motherless mother social group located in Blacktown. (Crisp & Taylor, 2010). 7. Provide strategies for Sally to read to Jake. (Crisp & Taylor, 2010). 8. Provide strategies for Sally to assess safety in her own home. (Crisp & Taylor, 2010). 9. Teach Sally the importance of listening attentively. (Holland, Jenkins, Solomon & Whittam, 2009). | 1. A full health assessment is required to assess the degree of malnourishment in Jake and to obtain a full and complete picture of his current health status, based on the height and weight that has been examined. This will aid in developing strategies which will assist Sally in promoting Jakes...
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