Nursing Care Plan
ASSOCIATE DEGREE NURSING
NURSING PROCESS FORM: PART I – ASSESSMENT
Student:
Date of Care: 3/4/13
Client’s Initial: WB Room # 1011 Occupation: Teacher
Age: 59 Sex: F Race: Black Religion: Christian
Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband
Stage in Life Cycle:
Generativity vs. Stagnation Surgery date(s) this admission:
N/A
Chief complaint:
Brain Dysfunction/Traumatic, closed injury Admission Diagnosis:
Post Blunt Force (Head) Trauma
Additional Diagnosis:
Type 2 DM; HTN; DM related Neuropathy
Past Medical/Surgical History (dates)
11/29/10 Dx w/ Pancreatitis & Hep B
Current Medical History:
59 y/o female AA pt w/ PMH of Type 2 DM; HTN; DM related Neuropathy, suffering from closed injury head trauma caused by basketball hoop and backboard falling on her head. A CAT scan of her head & cervical spine came back negative for fractures. She was scheduled for DC from ED but b/c of her vision; gait problems; and persistent headache, she was admitted to West Towerfor inpatient rehab and continued med evaluation.
Psycho-Social History:
No Hx of tobacco, alcohol or illicit drug use. Lives in own one-story home. Widowed for 5 yrs. Has 25 yrs as a school teacher, Has family support (daughters).
NURSING PROCESS FORM: PART I
PATHOPHYSIOLOGY OF CURRENTDIAGNOSIS
FROM TEXTBOOK
Diagnosis and Definition of Diagnosis:
Dx: Post Blunt Force (Head) Trauma
Definition: a usually serious injury caused by a blunt object or collision with a blunt surface (as in a vehicle accident or fall from a building)
Etiology:
While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma.
Motor vehicle accidents account for almost half of the TBIs in the United States, and in
NURSING PROCESS FORM: PART I – ASSESSMENT
Student:
Date of Care: 3/4/13
Client’s Initial: WB Room # 1011 Occupation: Teacher
Age: 59 Sex: F Race: Black Religion: Christian
Admission Date: 3/1/13 Primary Language: English Role in family: Widowed from husband
Stage in Life Cycle:
Generativity vs. Stagnation Surgery date(s) this admission:
N/A
Chief complaint:
Brain Dysfunction/Traumatic, closed injury Admission Diagnosis:
Post Blunt Force (Head) Trauma
Additional Diagnosis:
Type 2 DM; HTN; DM related Neuropathy
Past Medical/Surgical History (dates)
11/29/10 Dx w/ Pancreatitis & Hep B
Current Medical History:
59 y/o female AA pt w/ PMH of Type 2 DM; HTN; DM related Neuropathy, suffering from closed injury head trauma caused by basketball hoop and backboard falling on her head. A CAT scan of her head & cervical spine came back negative for fractures. She was scheduled for DC from ED but b/c of her vision; gait problems; and persistent headache, she was admitted to West Towerfor inpatient rehab and continued med evaluation.
Psycho-Social History:
No Hx of tobacco, alcohol or illicit drug use. Lives in own one-story home. Widowed for 5 yrs. Has 25 yrs as a school teacher, Has family support (daughters).
NURSING PROCESS FORM: PART I
PATHOPHYSIOLOGY OF CURRENTDIAGNOSIS
FROM TEXTBOOK
Diagnosis and Definition of Diagnosis:
Dx: Post Blunt Force (Head) Trauma
Definition: a usually serious injury caused by a blunt object or collision with a blunt surface (as in a vehicle accident or fall from a building)
Etiology:
While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma.
Motor vehicle accidents account for almost half of the TBIs in the United States, and in