Sample Resume : Nursing Care Plan

1506 Words7 Pages
NURSING CARE PLAN Student Justin De Vera Date 3-12-16 Instructor Professor Vaughn Course 316L Patient Initial X.L Unit/ Room# 310 DOB 12-21-1989 Code Status Full Code Height/Weight 5’6’’ and 150 lbs. Allergies NKDA Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 97.8 F 74 18 99% Room Air 125/78 7/10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations X.L is a 26-year-old Chinese female who was brought to Montclair Hospital on 3-11-16, X.L was brought to the hospital by her sister and niece because X.L…show more content…
Patient was on normal diet but was placed Nothing by mouth by the end of the day due to patient’s physician Dr. Lee stating that X.L was about to give birth and that she needed to be place NPO in case if X.L would need to have an caesarean section (C-section). Patient had normal breath sound, heart sounds, and bowel sounds heard throughout all quadrants. Patient had limited movement. Patient stated that she was fatigue, anxiety level of 6/10 and pain level of 7/10. Patient had a temperature of 97.8 F, heart rate 74 respiration rate 18, Pulse O2 99%, Blood Pressure 125/78, pain level 7/10. All vital signs are in normal ranges and pain medication will be given to decrease X.L pain level (D 'Amico & Barbarito, 2012). Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations ABG Values 3-11-16 CBC 3-11-16 CMP 3-11-16 Lab Value Names Patient’s Lab Values Normal Lab Values RBC 3.90 Low 4.20-5.40 WBC 6.3 4.8-10.8 Hemoglobin 12.3 12.0-16.0 Hematocrit 36.7% 36-48% Platelet 153 140-450 Neutrophils 67.7% 42.2-75.2 CO2 33 Low 35-45 O2 95 80-100 HCO3 23 22-26 pH 7.41 7.35-7.45 O2 saturation 99% 95-100% Na 139 135-146 K 4.2 3.5-5.1 Cl 106 98-107 BUN 9 7-18 Creatinine 0.8 0.6-1.3 Albumin 2.8 LOW 3.4-5.0 Glucose
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