nursing care plans example
PATIENT HEALTH ASSESSMENT Student’s Name: Antonina Polukhina
Date: 4/1/2015
Clinical Facility: NCMC
PHYSICAL ASSESSMENT: Patient Initials: S. E. Age: 58 y. o. Sex: Female
Admitting Diagnosis: weakness/dizziness
Vital Signs: Temp. 97.4, Pulse 106, Respirations 18, BP 118/56
Ht/Wt/BMI: Height = 167.64 cm, Weight = 84.878 kg, BMI 30.2
Skin/Wounds: (Skin turgor; presence of any skin breakdown; incisions; wounds.)
Subjective: patient denies any skin breakdowns. Objective: leg skin is shiny and has several enlarged veins, otherwise, skin is pale and evenly pigmented, no lesions or excoriations, good turgor. Nails are light pink, adhere to nail bed with 160-degree angle. Hair is grey, shiny and full; amount and distribution appropriate for age and gender, no flaking. Saline lock, right antecubital, patent, intact, little bruising, but no sighs of infiltration or inflammation.
Eye, Ear, Nose, & Throat: (PERRLA; general hearing; nasal congestion/drainage; mucus membrane color/moist; complaints of difficulty swallowing.)
Subjective: patient has glasses, denies hearing problems, nasal congestion. Patient states she can’t swallow her food unless it’s chopped and grinded, no tonsillectomy.
Objective: PERLA, hearing intact, nasal patency X2, mucous membranes are moist and pink. Gag reflex intact. Thyroid is not enlarged.
Pain Status: (Level of pain; location, intensity, characteristics, activities which cause/worsen pain; activities which alleviate pain)
Subjective: patient complains of abdominal pain, nausea, and chest pain.
C: dull
O: this morning
L: chest, back, stomach
D: intermittent
S: 8
P: walking makes it worse, but it’s tolerable when she is in bed
A: nausea, dizziness
Objective: patient is uncomfortable when getting up from the bed, grimacing, patient is nervous.
PHYSICAL ASSESSMENT: continued
Cardiovascular: (Rate & rhythm; presence of adventitious sounds (murmurs); peripheral pulses – strength and equality)
Subjective: patient states she
Date: 4/1/2015
Clinical Facility: NCMC
PHYSICAL ASSESSMENT: Patient Initials: S. E. Age: 58 y. o. Sex: Female
Admitting Diagnosis: weakness/dizziness
Vital Signs: Temp. 97.4, Pulse 106, Respirations 18, BP 118/56
Ht/Wt/BMI: Height = 167.64 cm, Weight = 84.878 kg, BMI 30.2
Skin/Wounds: (Skin turgor; presence of any skin breakdown; incisions; wounds.)
Subjective: patient denies any skin breakdowns. Objective: leg skin is shiny and has several enlarged veins, otherwise, skin is pale and evenly pigmented, no lesions or excoriations, good turgor. Nails are light pink, adhere to nail bed with 160-degree angle. Hair is grey, shiny and full; amount and distribution appropriate for age and gender, no flaking. Saline lock, right antecubital, patent, intact, little bruising, but no sighs of infiltration or inflammation.
Eye, Ear, Nose, & Throat: (PERRLA; general hearing; nasal congestion/drainage; mucus membrane color/moist; complaints of difficulty swallowing.)
Subjective: patient has glasses, denies hearing problems, nasal congestion. Patient states she can’t swallow her food unless it’s chopped and grinded, no tonsillectomy.
Objective: PERLA, hearing intact, nasal patency X2, mucous membranes are moist and pink. Gag reflex intact. Thyroid is not enlarged.
Pain Status: (Level of pain; location, intensity, characteristics, activities which cause/worsen pain; activities which alleviate pain)
Subjective: patient complains of abdominal pain, nausea, and chest pain.
C: dull
O: this morning
L: chest, back, stomach
D: intermittent
S: 8
P: walking makes it worse, but it’s tolerable when she is in bed
A: nausea, dizziness
Objective: patient is uncomfortable when getting up from the bed, grimacing, patient is nervous.
PHYSICAL ASSESSMENT: continued
Cardiovascular: (Rate & rhythm; presence of adventitious sounds (murmurs); peripheral pulses – strength and equality)
Subjective: patient states she
References: Gulanick, M., Myers, J.L. (2013). Nursing care plans. Diagnose, interventions, outcomes. USA: Mosby.