) Chief Complaint or client’s request for care Present Illness: Present Illness or present health status OLD CART (Onset‚ Location‚ Duration‚ Characteristics‚ Associated factors‚ Response to treatments tried) Progression of disease/Illness: Chronological order of events Specific s/s Duration‚ characteristics‚ location Abrupt/gradual‚ related
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Nursing Care Plan for Rhonda Silverman (pseudonym) Introduction Rhonda Silverman is a 89 year old female who is currently residing in a rest home. She formerly worked as a short hand typist prior to her marriage after which she had 3 children and was actively involved in volunteer work within her community while her children were being raised. Rhonda has had a very active life and loves to travel. She has visited North America‚ Europe‚ Asia and Oceania. As she has aged her health as deteriorated
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OBJECTIVES OF CARE INTERVENTION PLAN‚ METHOD OF CONTACT‚ PROPOSED ACTIONS‚ METHOD OF TEACHING EVALUATION PLAN RESOURCES AVAILABLE IN THE FAMILY OUTCOME CRITERIA METHODS/TOOLS Presence of health deficit: Illness state related to elevated blood pressure Community Nursing Diagnosis: Inability to make decisions with respect to taking appropriate health action due to: a. failure to comprehend the magnitude of the condition b. Inaccessibility of appropriate resources for care‚ specifically physical
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NURSING CARE PLAN Nurs 326 SFSU Student Name: Alena Makarava Instructor/Clinical Site Gerardo Caritan‚ RN‚ MSN Date: 2/26/2015 Ms. X is a 34 year old female. The patient is a G3 P2‚ with both children delivered by C-section‚ with the only complication in both being low birth weights. Ms. X has a longstanding history of hypertension‚ anxiety and depression. Additional health history includes a vitamin D deficiency‚ back surgery in 05/06 due to a herniated disc‚ and two previous cesarean
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3N Clinical Nursing Care Plan NURS 2230 Lakehead University October 2‚ 2014 I declare that this paper is my original work. Excepting where I have cited my own previous work‚ this paper in its entirety‚ or any portion thereof‚ has not been submitted to meet the requirements of any other credit course. Student Signature: ____________________________________ Date: ____________________ Patient History In the context of this paper‚ the patient will be referred to as
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Nursing Diagnosis 1. Acute pain R/T: inflammation and obstruction of the gallbladder AEB: patient verbalizes abdominal pain of 7/10‚ grimaces‚ rubs his stomach‚ BP 158/79‚ T990F 2. Deficient knowledge R/T: lack of knowledge about the importance of incentive spirometer AEB: patient says that he does not know how to use and needs to know more about its importance. 3. Risk for deficient fluid volume R/T: restricted intake 4. Risk for imbalanced nutrition less than body requirement R/T: impaired
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Nursing Care Plan |Student | |Course |NURS 211L |Date |5/27/2011 | |Instructor | | | | | | |Patient Initial | _____J.G________ ___Age 59 Female_____
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Psychiatric Clinical Nursing Assessment Jennifer Stokes Daytona State College Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health‚ fear of physical illness‚ hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐
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COMMUNITY COLLEGE DEPARTMENT OF NURSING CLINICAL ASSESSMENT TOOL Subjective Data (Basic Conditioning Factors) Student: Date of Care: 10/03/09 Patient’s Initials: P. V. Age: 37 Room #: 3114 Bed 1 Allergies: Food: NKA Gender: F Medications: NKA Environmental: NKA Admitting Diagnosis: Pancreatitis Developmental Stage (Erickson and Havinghurst): (List Developmental stage and tasks‚ assess each task) 1. Selecting a mate: Although patient
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I. SAFE AND QUALITY NURSING CARE CORE COMPETENCY 1: Demonstrate knowledge based on health/illness status of individual/ groups Indicators : ○ Identifies health needs of patients/groups ○ Explains patient/group status CORE COMPETENCY 2: Provides sound decision making in care of individual/groups considering their beliefs‚ values Indicators : ○ Problem identification ○ Data gathering related to problem ○ Data analysis ○ Selection appropriate action ○ Monitor progress of action
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