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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Vol. 92/No.1 Risk Factors: People with a weak immune system‚ recent exposure with TB bacteria‚ immigration from area with high TB rates‚ IV drug users and people working in facilities at high risk for TB including hospitals‚ shelters‚ jails and nursing homes (Basic TB Facts‚ 2010). Questions to ask Patient: Are you having any difficulty with breathing now? Are you having any shortness of breath? How long have you had a cough? Describe your cough. Are you bringing up any phlegm? If yes
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elimination related to urinary tract infection Goals: After 30 minutes of nursing intervention‚ the patient will be able to gain knowledge on ways of managing Urinary Tract Infection. Objectives: Within 15 minutes of nursing intervention‚ the patient will be able to gain knowledge by : Enumerating 2/3 specific causative factors of UTI. Demonstrate behaviors and techniques to prevent urinary tract infection and manage care of urinary catheter. Shows positive attitude by verbalizing understanding
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Nursing Care Plan Nursing Diagnosis | Patient Outcomes/Goals | Nursing Interventions | Rationale | Evaluation | 1. Risk for systemic infection r/t cellulitis AEB breakdown of tissue on the lower extremities 2. Chronic pain related to multiply system diseases‚ gout‚ cellulitis‚ as demonstrated by patient complaints of pain | 1. Pt will demonstrate progressive healing of tissue by discharge(Long-term) 2. Manage acute & chronic pain to pt. identifiable tolerable level of 4 on scale of
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Teaching Plan Cognitive behavioral Distortions Guided Imagery Learner Outcomes Content Outline Methodology Time Frame Evaluation 1. Learner will recite their understanding of the connection between our thoughts‚ feelings‚ and behaviors. 2. Learner will be able to recite one way in which positive thinking can improve one’s outlook on life and ones decisions Examples of current application of guided imagery—sports psychology‚ cancer‚ HIV. Definition of cognitive errors
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student. The little bit crowded before is now already spacious. It can now accommodate student nurses‚ nurses’ trainees‚ doctors‚ and staffs at the same time without so much crowding. And it feels nice to stay in this station after interacting and giving care to our patients. As I tried to look at every angle of this station and was trying to figure out what kept the station looks different‚ I figured out that the big cabinet that was inside the station was no longer there. That’s the main reason why
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Plan‚ Implement and Evaluation Thama Bradshaw ITT-Technical Institute Abstract In the following document I will discuss Plan‚ implement‚ and evaluate components of the nursing process at length. I will define the plan‚ implement‚ and evaluation in the nursing care process. While showing how it is used in the nursing field. Plan‚ Implement and Evaluation The nursing process is an organizing framework for professional in
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UNIT CU1520 Questions 1 – Be able to assess the development needs of children or young people and repare a development plan. 1.1 – Explain factors that need to be taken into account when assessing development. * Progress * Improvement * Behaviours * Look at goals within care plan are they on track? * What activities they are partaking in and how well are they dealing with them. * Whether they are interested‚ compliant and accepting or not. 1.2 – Assess
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ASSESSMENT (Data Collection) NURSING DIAGNOSIS (Patient Problem/Priority) PLANNING (Patient-Centered Goals) IMPLEMENTATION (Nursing Interventions) Nurse roles: Assess‚ monitor‚ use of communication techniques‚ patient education EVALUATION (Patient-Centered Goal Met?) Subjective: (what you heard the patient describe) Objective: (what you see‚ hear‚ smell‚ feel) *Use nursing diagnosis language 1 goal per physical What specifically will you do - as a nurse - to assist the patient
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& research Exploring Orem’s self-care deficit nursing theory in learning disability nursing: Philosophical parity paper: part 1 In a two-part article‚ Paul Horan and colleagues explore the relevance of this popular nursing model from a variety of perspectives. Can Orem’s self-care deficit nursing theory be helpful in meeting the needs of people with learning disabilities? (Taylor 2002) and is one of the most frequently used theories in general nursing practice (Alligood and Marriner-Tomey
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