Nursing Care Plan Essay

Nursing Care Plan Student Vincent Estacio Course Nurs 210 skills Date March 2015 Instructor Patient Initial T.M. Age 32 Height/Weight 5’11 190 lbs Code Status Full Code Allergies N.K.A Unit Telemetry Room# Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 101 115 31 90% on oxygen 2 L/min via nasal cannula 170/96 4 History of Present Illness including Admission Diagnosis& Relevant Physical Assessment Findings (normal & abnormal)

Patient: M.H. 80 year old female experiencing renal failure. Chronic Kidney Disease (CKD) is a disease that is described as a loss of kidney function gradually over time. As kidney function decreases, the waste collection in the body’s blood becomes high and makes the individual feel sick. This disease can lead to other complications in the body such as anemia, poor nutritional health, high blood pressure, and nerve damage. These complications will begin to progress and show as CKD progresses

Nursing Care Plan 1. Assessment Subjective data. Patient report rash on her face for 1 week. Itching and painful lesions. Objective data. Several erythematous plaques scattered over the cheeks and the bridge of the nose. 2. Nursing Diagnosis Impaired Skin Integrity related to changes in the barrier function of the skin as evidence by disruption of skin surface, erythematous plaques and pruritus on cheeks and nose. 3. Planning Short-term goal. The patient will be able to maintain skin integrity without

S. To determine the future care plan, a teleconference was scheduled with individuals from few community organizations, complex care coordinator as well as, Fraser health and Interior health authorities. During this case conference, the patient’s history was discussed and each of the individuals offered their perspective based on

An example of how I have used evidence-based care for a patient was using the stroke protocol. As soon as the patient arrives to the ED whether it was by EMS or private vehicle and is suspected of having a stroke(CVA), a code white is called. The nurse that will take care of the patient at first will transfer the patient over to get a CT scan, a tech will assist as well to get all the patient information they can to enter them into the computerized system, and a physician will go as well. Once the

Formal Care Plan 1. Health History a. Biographical Data - The client is a 69-year-old female, born January 19, 1950. She lives in Lovington, New Mexico with her husband of 49 years. She has two adult children and they also live in Lovington. She has a high school education and described her occupation as a homemaker. She now resides in an assisted living facility because her husband is unable to provide her with safe, effective care. He states that she is paralyzed from the waist down and is fully

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

opportunity to care for two female patients – 205(1) and (2). The first patient, 205-1, was admitted with respiratory distress and had a past medical history of hypertension, schizophrenia and bipolar disorder. She was initially put on 2 L/min of oxygen and placed on oxygen titration protocol with orders to maintain O2 saturations between 88-92%. The patient was oriented to person and place, but had difficulty with time. She was also obese (BMI 30) and deemed a moderate assist with ambulation. Her care plan

My nurse coach assisted Self Care Plan in helping me realize that setting aside time for myself is essential. Doing nothing for an hour or so a day, can grant me time to focus fully on myself, how things are going whether it is in my college life or my personal life. According to the textbook Holistic Health: A Guide to Living a Balanced Life Taking care of ourselves is a fundamental part of life. My physical health should be at the top of my list yet it poses as a challenge for me. To promote good

to the care that is delivered to a patient and examine the significance of the use of models and frameworks in the nursing process. It is intended to identify a patient with biopsychosocial needs that requires nursing intervention. Their holistic plan of care will then be critiqued in relation to the nursing model and framework utilised by the nursing staff. Knowledge will be demonstrated of the importance of utilizing evidence-based practice when creating an individualized plan of care. “The