Nursing Care Plan For Nursing

3666 Words Aug 1st, 2014 15 Pages
Nursing Care Plan

Student: Caitlin Dade Course: NURS 101L Date: 8/01/14

Instructor:
Mr. Hocevar

Patient Initial:
O.D. Age: 43
Height/Weight:

188lbs/5’5”
Unit: Medical Surgery Room# 4210

Code Status: Full Code Allergies: NKDA

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 97.2 F orally 110 BPM radial 21 RR 97% RA 109/60 mmHg 0/10

History of Present Illness including Admission Diagnosis
Relevant Physical Assessment Findings(normal & abnormal) Relevant Diagnostic Procedures/Results & Surgeries
(include dates, if not found state so) O.D. is a 43 year old Hispanic female who was brought into the emergency room (ER) by an ambulance because she was having another episode of gynecologic hemorrhage. She has uterine fibroids, which are benign tumors so these cause her to bleed excessively. She could not get her self to stop bleeding so her son called the paramedics (911) and they came and picked her up. She lost so much blood during this hemorrhage incident. O.D. is awake, alert, oriented to person, place, event, and time. The female patient speaks Spanish but she can speak basic English and I am able to communicate with her without an interpreter. The patient experienced chronic blood loss, and…

More about Nursing Care Plan For Nursing

Open Document