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 is single, she has many friends. Patient was happy to introduce her friends that came to visit. Introductions were all made as friends, no boyfriend or husband mentioned. 2. Starting a family and raising children: Patient is not interested …show more content…
using bathroom Foley catheter N Suprapubic tube N Urine clear Y Color yellow-amber Y Yellow Amount (cc's) n/a Continuous bladder irrigation N Lab Data (explain abnormal values) RANGE WBC: 4.5 - 11.0 HGB: Men 14.7 - 16.1 Women 9.3 L 12.0 16.0 May indicate anemia. HCT: Men 42.0 - 52.0 Women 27.1 L 37.0 47.0 May indicate anemia, bone marrow dysfunction, malnutrition, over hydration Platelet 490 H 150.0 - 450.0 Could indicate hemorrhage or inflammatory disorder. Glucose 83 70.0 - 110.0 WNR Sodium 140 135.0 - 145.0 WNR Chloride 103 95.0 - 110.0 WNR Potassium 4.3 3.5 - 5.1 WNR
Since the early 1900’s nurses have been trying to improve and individualise patient care. In the 1970s this became more structured when the nursing process was introduced by the general nursing council (GNC), (Lloyd, Hancock & Campbell, 2007) .By doing this their intentions were to try and understand the patient in order to give them the best care possible (Cronin & Anderson, 2003). Through the nursing process philosophy care plans were written for patients. It was understood that this relationship would ensure the patient received the best care possible to suit them individually. This would consist of not just the patient as a physical being but their spiritual emotional and holistic being also (Cutler, 2010). The
This week, I was given the opportunity to care for two female patients – 205(1) and (2). The first patient, 205-1, was admitted with respiratory distress and had a past medical history of hypertension, schizophrenia and bipolar disorder. She was initially put on 2 L/min of oxygen and placed on oxygen titration protocol with orders to maintain O2 saturations between 88-92%. The patient was oriented to person and place, but had difficulty with time. She was also obese (BMI 30) and deemed a moderate assist with ambulation. Her care plan included total assistance with ADLs, smoking cessation and oxygen protocols, limited salt intake (3mg), and chronic pain management. The second patient, 205-2, was admitted with a right pelvic fracture and had
DOI: 7/20/2015. The patient is a 56-year-old male elementary school worker who sustained a work-related injury while moving tool and materials in a milk crate between floors.
The first patient I witnessed was a 25 year old female. Pertinent patient medical history is anxiety, depression, and sleep dysfunction. The referring diagnosis is Chondromalacia of the right patella, which is also known as runner’s knee, is a condition where the cartilage on the undersurface of the kneecap deteriorates and softens. The physician who referred the patient, Victor N. Egwu, MD, orders the PT to evaluate and treat three times per week for four weeks. Right knee ROM and strengthening exercises should be done to treat patient. The PT evaluation justification history includes 1-2 person factors examination is addressing three or more elements. The clinical presentation is stable. The clinical decision-making is low co-morbidities.
This essay covers the Key concepts of care. In 2013 the Francis report highlighted the need for student nurses to test and experience their values and levels of care and compassion, and whilst it is seen that the failures highlighted in the report go further than a lost compassion of nursing, this exercise is to look at the key concepts of care and the principles of the 6 Cs (Care, Compassion, Courage, Communication, Competence and Commitment) which have been identified as fundamental values, although not the only ones as nurses have other core values such as organisational, professional and NHS values to work to. I have selected one of the 6 Cs (communication) for a more detailed description from which I will then provide as requested in my brief an example specific to its application in a particular service. The area I have selected to apply this to, is Dementia.
Implementation of a practice change requires the innovator to be able to describe the process of implementation, specifically addressing the methods utilized, with an assessment of the key components of the implementation plan. The Daily Safety Briefing (DSB) initiative does not gather new information, but it does present information in a new way. There is no requirement for subject consent, as safety reporting is already covered under the umbrella of a consent to treatment, which patients sign at the time of admission (Hughes, 2008). Existing safety reports will be summarized into a one page document that will be presented at the DSB.
IntroductionThis article touches up on many main points in Nurse Assisting. Authors talk about manynew ways to implement change in Long Term Care Originations. They talk about teamwork,training, and enhancing work strategies. I definitely agreed with this article, with wanting to be aCNA and depending on where I end up working I think it is good that people are wanting tomake these changes.DevelopmentSome key points in this article were how integrating new recruits to manage heavyworkloads in LTCOs can be hard to manage, the enhancements of informal work strategies, andthe debate on if teamwork is a “deterrent to change” or a “lever for change”. Somethings I foundstriking about this article was the heavy load management. In the article one nurse assistantexplained that during training they are told to take all the time the need, but when you startworking in the organization they are told they have 45 minutes with a resident, but actually haveno more than 15 minutes.
The profession of nursing includes: promoting health, preventing illness, as well as providing care. NUR 102 teaches student nurses, like myself, a wide range of information and knowledge needed in order to become a successful nurse and also aids in the preparation for clinical placement. Nonetheless, this course teaches essay writing, critical thinking, nursing theories, as well as the roles and responsibilities that I will have as a nurse.
R.O. is a 43-year-old female Latino patient who has been living at home alone since she got divorced three months ago. She does not have any living or available family in the United States. She is the oldest of three children. Her parents died of an accident when she was little. Two of her sisters live in Mexico. She has lost contact with her family in Mexico when she got married and move to the United States. She also has stopped communicating with her ex husband since they got divorced. Although she does not have any support from her family, she states that her church member has been very supportive. Moreover, R.O. states she was a homemaker until the divorce. Currently, she has been working as a dishwasher near her house.
One the most important issues facing nursing these days is the changing healthcare insurance industry. I saw how these changes affected staff firsthand. I worked at Quincy Medical Center for three years until it closed in December of 2014. The Affordable Care Act led to cuts to Medicaid supplemental payments for the uninsured and has forced many hospitals to reduce staff or close like Quincy Medical Center. This is a concern for nurses because under current federal regulations there are no specific requirements for nurse to patient ratios. Multiple research studies demonstrate that lower nurse-patient ratios save both lives and money long term. For example, hospitals that routinely staff with 1-to-8 nurse-to-patient ratios experience five additional deaths per 1,000 patients than those staffing with 1-to-4 ratios, according to the Journal of the American Medical Association. Higher nurse to patient traditions lead to higher burnout
|Physiological |2. mother has been observed |perineum secondary |during my shift, and |2. Instruct mother on the importance | |bathroom breaks, and |
be hung. First off for electrolytes we check results to ensure what the numbers were, everything
Throughout most of the shift, my nurse preceptor and I were in the patient’s room either evaluating her and the fetus, performing exams, taking vital signs, administering medications and fluids, charting, or reading the fetal monitoring strips. We also kept in regular contact with the physician to keep him up to date on the patient’s status and to receive new orders. We also spent a lot of time talking to the patient, her mother, and her boyfriend. They were concerned for the status of the mother and the baby. We explained to them that both the mother and the baby’s heart rate was high and their goal was to decrease them both. In addition, my nurse preceptor explained how we were administering Tylenol and amoxicillin to reduce the fever and
Chronic Kidney Disease (CKD) is a disease that is described as a loss of kidney function gradually over time. As kidney function decreases, the waste collection in the body’s blood becomes high and makes the individual feel sick. This disease can lead to other complications in the body such as anemia, poor nutritional health, high blood pressure, and nerve damage. These complications will begin to progress and show as CKD progresses to advanced stages. Early detection of this disease is essential when it comes to treatment. If CKD is diagnosed early enough the disease progression can be slowed down and managed. This disease will eventually lead to failure of the kidneys
Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen saturations of 85-95% 2L NP, immobility 95% of the day, and adventitious sounds throughout lungs (crackles) secondary to CHF, hypertension, pain caused by gout and arthritis, and obesity