Antepartum/Intrapartum Patient. Student Name: Patricia

The second step that I used in the nursing process was diagnosing. Based on my results from my assessment, I was able to use that information to come up with a couple nursing diagnoses. This step is used to offer effective nursing care because it helps me set an intervention and plan of care to help my patient’s health outcomes for the better.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting

The purpose of this assignment is to explore a needs orientated approach to care planning, through the use of a problem solving approach to care, and a nursing model. It aims to show an understanding of what both a problem solving approach to care, and a nursing model are; and to establish how various key elements of both are implemented in practice. The following citation by the Department of Health (DH) (2009) identifies what is intended by the process of care planning;

Problems 1 - 3 with defining characteristics, expected outcomes, nursing interventions, evaluations of interventions and evaluation of overall goal attainment. (Met, not met, partial/Continue plan/revise). Be sure to use the AAMT format for each problem: A = Assess/ Monitor for problem; A = Actions/Nursing Interventions for problem; M = Medications for problem/why useful/source/See TACTIS; T = Teach what to the patient/family about the problem?/Why? Source.

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may

Write one goal and one measurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural considerations for this client.

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

S- 3671 dispatched to a m pt C/O of abdominal pain and black stool. Pt is a 49 y/o m whose C/C is abdominal and lower back pain. Pt also states that he is experiencing cramping around his left ribcage. Pt states that he has been experiencing N/V/D for the past four days. Pt also states that his bm's have produced black, watery stool since the monday prior to the incident date. Pt is able to provide EMS personnel with a detailed medical Hx that includes HIV, acid reflux, and recently diagnosed COPD. Pt also states that he recently stopped smoking cigarettes. Pt is also able to provide EMS personnel with a list of medications that he is currently taking that includes Duloxetine, Stribild, Ranitidine, Aripiprazole, oxycodone, and proair. Pt states that he has not taken any of his prescribed medications for the past four days prior to the incident date. Pt states that he has allergies to Kaletra and gabapentin. Pt states that his primary

My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a

This assignment will investigate a needs orientated approach to care, critically discussing the nursing process. It aims to show an understanding of what a nursing model and the nursing process is, looking in detail at the relationship between this nursing process and the Roper, Logan and Tierney (RLT) model of nursing. This essay will explore how the nursing model and process is implemented in practice, considering how the RLT model assists nurses to adapt a problem-solving technique when developing care plans for individuals. Strengths and limitations of the RLT model and the nursing process, in relation to developing care plans, will be critiqued along with the effectiveness of

This 49-year-old African-American female was presented to Truman Medical Center - Emergency Department, on November 24, 2014 due to nausea, vomiting, and headaches for two days. She stated that she has no appetite and left lower quadrant pain. She was previously treated at Saint Luke Hospital - Emergency Department for her diarrhea, nausea and vomiting before transferred to TMC Hospital. At SLH - ED, she was given some Benadryl, Tylenol and IVF which showed no improvement and continue to have three to four times watery diarrhea with no blood or mucus associated with nausea and vomiting. Her medical history is significant of diabetes mellitus type 2, hypertension, intracardiac loop recorder and cerebro-vascular disease. Vital signs included a high oral temperature

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the

This essay will explore a needs orientated approach to the care that is delivered to a patient and examine the significance of the use of models and frameworks in the nursing process. It is intended to identify a patient with biopsychosocial needs that requires nursing intervention. Their holistic plan of care will then be critiqued in relation to the nursing model and framework utilised by the nursing staff.

This portfolio entry requires an assessment and care plan to be presented incorporating the nursing process based on a client that I assisted in the care of during my clinical placement.