Care Plan Worksheet Student: Date of Care: Age/Gender: Rm Number: Code Status: full Allergy: NKA Admitting Diagnosis : embolic cerebral vascular accident (CVA)‚ right side Current Medical/Surgical Diagnosis: chronic left ventricle thrombus on anticoagulant‚ hypertension‚ chronic kidney disease stage 3 Past Medical/Surgical History: metastasis of prostate cancer‚ primary; bone cancer‚ secondary; cardiomyopathy‚ a central hypertension‚ left bundle branch lock‚ past substance abuse
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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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PN 0004C Weekly Clinical Planning Sheet Student Name: S.H Care plan #5 Patient Initials: t.l Age/Sex: 73/f Allergies: Potassium Nurse on Duty: Regin Admission Date: 06/29/2013 Admitting Physician: Dr. Cole Consulting physician: Code status: Hospice‚ dnr Activity Level: As tolerated Diet: nectar thick/puree Patient History and Diagnoses: primary
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the patient with acute abdominal pain NS344 Cole E et ai (2006) Assessment of the patient with acute abdominal pain. Nursing Standard. 20‚ 39‚67-75. Date of acceptance: October 10 2005. Summary Abdominal pain has many causes‚ from simple to complex presentations. Patients with abdominal pain may have a number of physiological and psychological needs. Nurses have a key role to play in patient assessment‚ history taking and management • Identify the main causes of abdominal pain and differential
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Extrapyramidal side effects: p. 789- A variety of signs and symptoms that are often side effects of the use of certain psychotropic drugs‚ particularly the phenothiazines. Three reversible extrapyramidal side effects are: acute dystonia‚ akathisia‚ and pseudoparkinsonism. A fourth‚ tarditive dyskinesia‚ is the most serious and is not reversible Akinisia: p. 784- regular rhythmic movements‚ usually of lower limbs; constant pacing may also be seen; often noticed in people taking antipsychotic medication
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Indiana Nursing Program – Region 6 Nursing Care Plan and Evaluation Student: __ Instructor: _Date: _1-28-2010_____ Instructions: 1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2. All nursing care plans must be typed (Times New Roman‚ 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course. 3. The grading rubric must be attached – last page of nursing care plan. 4. All
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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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Postpartum Hemorrhage Introduction Postpartum hemorrhage (PPH) is a significantly life-threatening complication that can occur after both vaginal and caesarean births (Ricci & Kyle‚ 2009). Simpson and Creehan (2008) define PPH as the amount of blood loss after vaginal birth‚ usually more than 500mL‚ or after a caesarean birth‚ normally more than 1000mL. However‚ the definition is arbitrary‚ attributed to the fact that loss of blood during birth is intuitive and widely inaccurate (Ricci & Kyle‚ 2009)
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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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NURSING PROCESS TEACHING CARE PLAN SUPPORTIVE DATA ---------------------------- Subjective: Pt states “my pain is still at 8/10‚ is my medication working?” Objective: 1. DX-UTI & possible urosepsis‚ Hip Fracture and fall during not a candidate for surgery‚ CHF 2.Buck’s traction applied 3. Assessment: Limited mobility‚ SOB
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