ASSESSMENT & CARE PLAN CLIENT CASE STUDY #2 Student: Fall 2010 Client Initials: VC Age: 82 Gender: Female Date Admitted to Nursing Home: 12/14/07 Assessment Date: 12/3/10 1. HEALTH HISTORY Brief description of health history and reason in nursing home: VC has a history of malignant neoplasm of her large intestine which lead to her colostomy status. She also has a history of fracture and fall. She was admitted to the nursing facility secondary to her alzheimer’s diagnosis
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cessation‚ diabetes and cholesterol management‚ nutrition planning‚ and personal training. HealthCentral.com which was founded by Jane M. Martin‚ a Respiratory Therapist with a degree in Elementary Education and over 30 years experience in respiratory care‚ who promotes understanding of COPD through posting educational materials that are easy to understand‚ and actively responding to patient posts and questions. BreathingBetterLivingWell.com was also founded by Jane M. Martin. The main patient
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percentage left for the employee is increasing as many companies are paying less and less of the cost. In 2007‚ employer health insurance premiums increased by 6.1 percent - two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $12‚100. The annual premium for single coverage averaged over $4‚400[1]. The cost of family health insurance nationwide is increasing dramatically for employees without anywhere near an equivalent increase
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COMPLETING A CARE PLAN A document or a personal record of the health conditions which stands as a mutual agreement between patient and his/her health care professional is referred to as a “Care Plan”. Usually a person with a health condition of long term opts for a care plan as it is helpful in assessing the care required and to be provided. A care plan is generally opted by the patient by insisting it to their GP or any other healthcare professional as this could help in improving health conditions
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Nursing care plan Name of client: Miss Ng Sex: F Date of assessment: 31/10/2014 Medical diagnosis: Caesarian section Diagnostic statement: Impaired comfort related to tissue trauma and reflex muscle spasms secondary to surgery as evidenced by vomiting Assessment Nursing diagnosis Goals & expected outcome Nursing interventions Rationales Method of evaluation Subjective data: 1. Patient reported of abdominal pain. 2. Elevated scoring of 8/10 of pain score Objective data: 1. Restlessness 2. Facial
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Assessment Data J.D. is a 67 year old‚ African American male. He is currently single‚ living alone‚ and has one son that lives in New York. He is a family oriented man that has many family members that live locally. J.D.is religious and is currently a deacon in his local church. He is dating‚ but has decided to abstain from sexual activity unless he remarries. J.D. has experimented with drugs‚ alcohol‚ and cigarettes‚ but reports he has not used any of these substances in the past 7 years.
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Karisa M. Young April 28‚ 2005 Nursing 374L Nursing Care Plan Twin ‘B’ was born on Monday February 14‚ 2005 at 35 weeks gestation. The mother was scheduled for a cesarean section at 38 weeks gestation‚ but presented in the hospital early with signs of labor. A cesarean delivery was performed. Twin ‘B’ APGAR scores at 1 minute and 5 minutes were 9 and the newborn weighted 4lbs 3 oz. Upon completion of the assessment‚ the newborn’s temperature decreased to 96.1 degree Celsius (axillary). Diagnosis
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NURSING CARE PLAN GUIDE ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient. |ASSESSMENT |PLANNING |EVALUATION | |Universal
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WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM NURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy Patient intials: R.M. Confidential Marital Status: SINGLE Student’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary Servey Admittance date: 3/12/12 Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPO Allergies: None
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