Nursing Case Plan Sample

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.

CPSW met with Ms. Bensalih at her home. Ms. Bensalih stated that she has not done any UA's or chemical assessment at Tubman Chrysalis Center. She stated that she been participating her therapy session at Associated Clinic psychology and that her last visit was on 9/20/16 at 5:00pm. Ms. Bensalih stated that she will be doing a walk in at Chrysalis Center on 9/28/16 and that she will call CP for un update. She stated that she has been busy and overwhelmed most of the time. CPSW reminded Ms. Bensalih that she needs to participate and complete her case plan asap. Ms. Bensalih stated that she will call CP tomorrow 9/28/16 to updated the progress to this writer about the walk in appointment at Chrysalis Center. Ms. Bensalih stated that she has

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

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.

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

Mrs. Wilson is seen in her room at Glenbridge Nursing Home on 02/28/2018. She had an episode last night of chest pain. She is so ebullient and distracted that it is hard to get a straight history, it came on when she was asleep but she may been sitting up. She was seen by a nurse, a sat was taken. I am not sure if there were other orders taken, but there is none on the chart. She says that she spent most of this morning in the bed and still feels tired, but she does not think she broke out in a sweat. She was more short of breath. She is calling it is a "stroke." I had tried to begin tapering her diazepam by discontinuing the morning dose and apparently all daytime clorazepate was discontinued by error and she gets it only at night.

The patient tells me that she is unsure when her last menstrual cycle was. Her periods are very irregular and she had not been keeping track of it. She and her husband have been attempting pregnancy for the last year and a half and she tells me that as of Thursday, August 27th, she and her husband had gone through the procedures for adoption. She said that she knows she ovulated on August 18th. She was using an ovulation kit. She took a home pregnancy test on the 28th, which was positive, repeated with a different brand of test on the 29th and that was also positive. She has a regular gynecologist with York Gynecology, Robert Cervenka, MD, that she uses regularly, and she already has an appointment with him

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

Mission: One church, one heart one purpose advancing health awareness and providing people with tools to take responsibility for their health through early detection and prevention. The project is a public health intervention event with interactive and educational information with screenings and basic preventive medicine for the community.

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,

There are many pros for Joe taking a position on the same unit that he already work as an aid. Joe is familiar with the unit and were everything is located. He knows the type of patients they have. He is familiar with everyone that works on the unit. He has a relationship with his coworkers and physicians. Joe is familiar with the software and equipment used on the unit.

The purpose of the nursing practice field experience is to enhance leadership and research skills; identify shortcomings in policies, procedures or processes; and improve the current processes to ensure optimal patient-centered, healthcare delivery through the use of up-to-date evidence-based resources.

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

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

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