RN Program CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN NURSERY STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/Nursery CLINICAL DATE: 01/20/15 PATIENT INTIALS: F.P. AGE: 9 days Sex: M RELIGION/CULTURE: Not documented MATERNAL AND LABOR HISTORY: Mother was admitted to hospital on 01/09/15 for labor induction at 39 weeks and 4 days. Active labor began at 1015. F.P. was born at 1837
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assessment‚ planning‚ implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements. My preceptor had explained to me the process involved in care planning for a patient on the unit‚ the doctor will do the majority of the assessment‚ the nurse carries out the risk assessment and completes Roper Logan and Tierney nursing assessment which is the nursing model used by the Louth/Meath services. The nurse also carries
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Data Base and Nursing Care Plan Student Name: Date: Pathophysiology (Include Normal Physiology‚ identify the Physiological Alteration‚ identify sings and symptoms). M.P. is a 56 year old African American male‚ with a history of progressive multiple sclerosis with multiple contractures‚ chronic decubitus ulcers‚ chronic indwelling urinary catheter and known osteomyelitis (infection of the bone). Mr. P. was admitted on October 25th with sepsis‚ a systemic response to infection.
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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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Module III Nursing AVS Transition Nursing Process Discussion Group 3 Case Study Michael Martinez is a 24-year-old Marine who was involved in a motor vehicle accident (MVA) while on leave. His face hit the dashboard‚ resulting in a fracture of the mandible. Yesterday‚ he underwent a surgical maxillomandibular fixation‚ (wiring of the jaw) for stabilization of the fracture. As a result of this surgery‚ he is unable to open his mouth and is limited to a liquid diet. The restricted diet
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References Student X Baton Rouge General School of Nursing Nursing Care Plan for Herpes Zoster Patient Patient is a 33 year old African American female with infected herpes zoster‚ sepsis‚ and gastroenteritis. The patient was admitted to the Mid-City Baton General Hospital on Sunday‚ June 15‚ 2014 for infected herpes zoster‚ where a chest x-ray‚ blood culture‚ specimen arm wound culture‚ and urinalysis was performed. The results showed lungs clear‚ heart size with in normal limits‚ and no abnormal
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This essay will discuss the plan of care I developed for Mr X while he was under my care in a post anaesthetic unit. It will discuss my nursing assessments‚ and what diagnoses I developed from this. It will then discuss the rationale behind my nursing interventions using relevant literature. My plan of care will be analysed throughout while identifying how my nursing care meets best practice guidelines. A nursing care plan is begun at a patients admission. In this case Mr X was booked in for
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Care Plan Problem: Risk for bleeding r/t postpartum complications. Patient Centered Goal: Patient will not experience any abnormal/excessive bleeding by the end of clinical shift. Expected Outcomes: 1. Patient will experience lochia reducing in amount and lightening in color by the end of clinical shift. 2. Patient will observe fundus that is firm‚ midline‚ and decreasing in height by the end of clinical shift. 3. Patient will verbalize understanding of signs and symptoms
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Hospital/IU | Cultural/Ethnic Background/Needs: None | Religion: | Did not state | Primary Language: | English | Educational Needs: | Cognitive Impaired | Discharge Planning/Self-Care Needs: Discharged to hospice. Self-care deficit. | Admission Date: | 3/31/13 | Time: 0500 | | Admitted From: (Home‚ ECF or ?) | Nursing Home | Admission DX: | Aspiration related pneumonia | Chief Complaint (“patient’s own words” – PUT IN QUOTES): patient unresponsive due to cognitive impairment. | Medical HX:
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Camden County College Nursing Care Plan Student: Date:9/16/2103 Pt. Data Objective & Subjective Nursing Diagnoses Goals (Short & long term Interventions & Rationale Pt. Teaching Eval. Subjective Data Patient states “I am afraid all the steroids are going to make me fat.” And was crying Patient was asking questions about covering the butterfly rash. Patient showed concern about swelled hand. She stated she did not want to look “crippled. “ Objective Data Patient
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