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Nursing Care Plan & Basic Conditioning

Satisfactory Essays

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

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