Nursing Case Plan Sample

Internet or Professional Article Research and how the info in the article applies to your patient.

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.

UCM: CPSW received a phone call from Ms. Bensalih. CPSW scheduled office visit for Ms. Bensalih on 11/10/16 12pm at Brookdale office. CPSW asked about the phone calls and Ms. Bensalih not calling back. CPSW mentioned to Ms. Bensalih that this writer called to schedule office visit and Ms. Bensalih has not been sucussfull returning phone calls to her CPSW. CPSW mentioned to Ms. Bensalih that this writer is concerned about Ms. Bensalih not responding and following through with the department's recommendation. CPSW asked Ms. Bensalih to complete her UA's consistency and her color code is red. Ms. Bensalih stated that she did not complete any UA's at this time and that she will start doing UA's very soon. Also, Ms. Bensalih reported that she has done a random UA's at Tubman Chrysalis.

CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.

Question 2: I provide almost all of the care for assigned patients throughout the shift but may not have the same patients from their admission to discharge

UCM:CPSW spoke with Ms. Barksdale regarding her case plan and staying consistent with her UA's. Ms. Barksdale has not been consistent with her UA's and intaially we started color code Black and was changed to Orange. Her last UA's on 2/6/17 Positive Alcohol. CPSW called Ms. Barksdale and reminded to stay consistent with her UA's. Ms. Barksdale stated that she does not want to complete UA's anymore. CPSW reminded if she misses twice or positive than rule 25 referral needs to be completed . Goal 1-2

Rosa exhibits personality traits such as neuroticism, carelessness and introversion. Throughout her treatment, Rosa expressed that she experienced poor care from the health staff and became hostile and aggressive towards staff. Rosa also communicated that she had anxiousness towards the pain caused by her hip surgery and further aggravations of her injury that may have occurred due to movement or rehabilitation. From these instances Rosa displayed neurotic tendencies. Additionally, these tendencies may have caused Rosa to have lowered conscientiousness and openness to experiences in regards to health outcomes and rehabilitation. Throughout the case it is documented that Rosa was reluctant to engage with suggested health recommendations

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

Patricia is an 84-year-old female who is diagnosed with metastatic colon cancer (C18.9). She also suffers from anemia. Patricia underwent a right hemicolectomy and a partial omentectomy, with noted bulky adenopathy at the base of the mesentery again, this proved to be moderately differentiated adenocarcinoma with mucinous features with venous, lymphatic and perineural invasion present. 22/32 lymph nodes were involved with cancer, margins were negative, pathologically this was a T3 N2b cancer. Patricia was treated with 5-FU and leucovorin but still experienced disease progression, with adverse side effects and found to have metastasis to the liver and bone which is KRAS and NRAS wild type. Patricia is currently on Erbitux weekly. She is malaise,

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

As Dr. Iram Lee Flores, MD I can see myself being a board certified Family Physician in a medically underserved area in Texas such as Cameron or Hidalgo County. Having established my own medical practice, I will be affiliated with Knapp Medical Center and Doctors Hospital at Renaissance. The Dr. Flores MD clinic will be open Monday – Saturday from 8:30 a.m. – 8:30 p.m. where walk-ins are welcomed and new patients are accepted. Patients of all ages, backgrounds, etc. Some of my mornings will consist of visiting the hospital to check up on some of my patients. Followed by a return to the clinic in the afternoon where my team and I will give the patient the best quality care they can

Nursing care plans are structured nursing processes that identifyf patients “needs, goals, and progress, and identify current nursing interventions” (Caple, 2016, p. 1). Identification promotes communication with other health professionals providing care to the patient (Caple, 2016, p. 2). Care adapted holistically will meet the patients unique needs promotes positive outcomes (Caple, 2016, p. 1). This assignment introduces Mrs Adams (pseudonym) and briefly discusses her nursing management plan on day nine of admission. Her management plan developed by the nurse included input from a range of health professionals, friends and family. One important aspect of Mrs Adams nursing management plan explored in depth is oral cavity

The patient in case study number one presents with signs of pregnancy. A missed period, nausea, breast tenderness, and positive home pregnancy test (Schuiling & Likis, 2017). The estimated date of date of delivery on September 8th of the following year (2013) based on the Nagele's rule (Date 12/1 +8 days then month December - 3 months) (Schuiling & Likis, 2017). The patient factor related to the last menstrual period (LMP) led to this conclusion. This patient presents in the first trimester. Therefore, a prenatal workup is indicated.

My position is Case Manager Nurse, organize long-term care for their patients. Their goal is to treat their patients at ideal times to keep them healthy and out of the hospital. This type of nurse would be working with a specific group of patients which can be from different age groups and different illnesses that required long term for example, Cancer or HIV. Anything that a patient needs when it comes to their health, medical insurance, or any resources that they may need like housing, support group, etc. I will develop a plan that will help improve or stabilized a patient’s health.

Hippocrates' general standards and in addition a vows not to utilize restorative information to abuse human rights or common freedoms and to hone medication without separation or predisposition. It is significant for nurses or physicians to adhere to these basic principles of the hippocratic oath which is to do the patient no harm.Many healthcare providers have conveyed concern regarding absence of emotion in robots, suggesting that this is the component that will never make human caregivers obsolete(Huston 2013). My gap in research concerns whether patient’s feeling psychologically neglected can be attributable to the distraction of technological nursing carts by nurses. I am interested in technology and the evolution of technology moving forward.I always wanted to change the world