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12 Student Name__________________________________________________________ Date_______________________ S (Situation) Patient’s Report Age/Gender 79/Male Admission date 03.12.12 Code status FULL CODE Allergies NKA V/SR18, SPo2 97%
Room Air, P80, T96.6, BP115/55
B (Background) Past Health History Medical Chief Complaint Diagnosis: Weakness Past Medical Surgeries: Amputation of Hx: right big toe PTSD, 1997. Manic/Depressive,
Bi-Polar Disorder, BPH COPD.
A (Assessment) Patient Data Head-to-toe assessment** Patient is A&Ox3. Pupils are PERRLA. Oral mucosa is moist/pink & intact. Patient's speech is clear and he responds appropriately to conversation. Patient reports pain as a 5 on 1-10 scale. Skin: skin is warm/dry to touch color elsewhere on of the skin is normal for age/ethnicity. Capillary refill >3 seconds. PMI 84 with audible S1S2Lung sounds are clear bilaterally in upper & lower lobes. Bowel sounds are normoactive in all quadrants with no tenderness, or distention in the abdomen. Patient is continent of bowel & bladder. Patient wheelchair and full assistance for mobility due to overall weakness. Patient's last bowel movement was today (03.13.12). Stool was formed, moderate amount. Patient states that he has "had some prostate trouble in the past" but could not recall specifically and that it affects his ability to maintain a urine stream. Continued on reference page, out of room...
R (Recommendation) Plan & Action Assess possible relationship between patients weakness and medications. Assess patient's dietary/exercise habits at home. Educate the client about the importance of proper diet and exercise to increase metabolism/energy levels and maintain muscle strength.
Labs (indicate ; use the back of page if needed): See labs page Diagnostic Test(s): See Labs
Diet: Regular Diet Current Wt/Ht/BMI HT 71", WT153, BMI 21.3 Braden score: 15 Fall score: Isolation: No
Home Meds (name/dosage/route/time/indicatio n) See Medication Cards
Religious Beliefs: Athiest 8 Spiritual or cultural implications for care: None noted at this time
Not Measured I________________ clinical day
Not Measured O__________________________
*Refer to assessment reference/text (Chapter 3 of course text)
Assisted patient in ambulating to the restroom. both clients agreed.13.13.13. .13.12 03.13.13.12 03. Assisted the RN in administering PRN medication Transported 3 patients from 4 west to XRAY/CT 03.13.12 03.12 03.12 1700 1800 Assisted RN in educating client about proper diet and exercise and meeting the bodies needs.12 03.Narrative Documentation Date Time 1400 1500 1600 Documentation introduced myself to my patients and asked permission to be their student nurse. 03. Watched physician scope a patients stomach.12 1900 2000 Assisted my patient in shaving Assisted a post op patient in ambulating.
Causes: Cigarrette smoking is the leading cause of COPD. and even extreme dust. Medication treatments include: bronchodilators. increased sputum production. . chemical fumes. damage to the lungs and other supportive tissues. oxygen therapy. antibiotics. Surgical treatments can include l lung volume reduction surgery and even lung transplant. and constant damage of the alveolar walls. SOB.12 Medical Diagnosis Pathophysiology Definition: COPD is a broad term for the classification of several irreversible lung disease associated with dyspnea upon exertion and a reduction of airflow into and out of the lungs. Long term exposure to other lung irritants including pollution. Symptoms: Chromic cough.Medical Diagnosis Pathophysiology Student: Jody Monks Date: 03. inhaled steroids. Treatments: If you are a smoker and have been diagnosed. stop smoking. hyperactivity of the lungs. dysfunction of the cilia in the airways. and pulmonary rehabilitation. It also includes narrowing of the airways. frequent respiratory infections.13.
or increased sleepiness Complication #3: Loss of interest in activites previously enjoyed. nosebleeds. List interventions you would take to prevent the three complications: Complication #1: Complication #2: Complication #3: List the developmental stage you would place this client using Erickson’s stages of development: List the supporting assessment information used in placing the client in this developmental stage: Other information: Student: Jody Monks Source: Diguilio 2007 Date: 03. dizzy spells.13. insomnia. change in the color of sputum.Medical Diagnosis Pathophysiology SUMMARY OF CARE List three possible complications of the medical diagnosis that might be seen with this patient: 1) Chronic infections 2) Hypertension 3) Depression List signs and symptoms you would see with each complication: Complication #1: increased amount of sputum. Complication #2: dull headaches.12 . tightness/ chest pain.
12 03. If none is on the chart.13.6-6.3 These were the initial tests performed upon W/in normal range W/in normal range W/in normal range W/in normal range MCV MCH MCHC 03.12.84 16.12.12 03.12 03.1 patients admit to the VA hospital W/in normal range W/in normal range W/in normal range Student: Jody Monks Date: 03.12WBC .2 31.7 42.12.12 80-100 27-33 32-36 90.12 4.12.12. DIAGNOSTIC TESTS.12 03. diagnostic test or procedures.8 34.12. OR PROCEDURES List all the most recent labs.12 03.5-11 4.LABORATORY TESTS.6 4.12. list testing that might be done for this admitting diagnosis(es) Name of test or Date Normal Result Client result Previous client result and Nursing implications procedure completed date completed WBC RBC HGB HCT 03.2 13-18 40-54 10.
Direct client in proper breathing efforts.12 . (R) client is more likely to lose/maintain wt when changing for self not others 2. or have client sit upright in chair.e. Elevate head of bed. 3 Nursing Interventions w/ rationale (cite sources) 1. Client has maintained 97% Sp02 levels and states eased breathing. Student: Jody Monks Date: 03. Patient states feeling of getting deeper breaths 2. Set realistic goals for weight loss (R) 3Collaborate with DR/Nutritionist (R) develop and implement Evaluation: 1. Client asks to speak to nutritionist & physician about weigh loss and diet. Patient demonstrates proper breathing technique to assist client in taking control of situation esp. 3 Nursing Interventions w/ rationale (cite sources) 1. Client states reasons for losing weight. Client will state a desire and readiness to lose weight and change lifestyle within one week.13. Client attained desirable body weight with optimal maintenance of health. (R) This will promote maximum inspiration and releave pressure on diaphragm. Encourage ambulation as indicated.NURSING CARE PLAN Problem #1: ineffective breathing pattern R/T disease process Goal: Client will demonstrate SpO2 of >/=95% within 2 hours 3 Client Responses to Interventions Outcome: Client will maintain Sp02 SpO2 of >/=95% throughout hospital stay. Client sets goal of 1lb/week loss 3. Use professional references when citing sources. Problem #2: Goal: Imbalanced nutrition more than body requirements R/T excessive intake in relation to metabolic need. 3 Client Responses to Interventions Outcome: Client has lost 2lbs in one week. 2. comprehensive weight loss program & support. slow deep breat (R) Evaluation: 1. 3. Determine client's motivation for weight loss. Patient states easier to take deep breaths 3. during anxiety. text or EBP reference. 2. (R) To increase respiratory muscle strength. i.
Pt. text or EBP reference. 3 Client Responses to Interventions 3 Nursing Interventions w/ rationales (cite sources) 1. Involve client in developing Exercise plan/goals (R) to meet individual needs/desires/available resources.13.12 . Council client regarding individual health risk (R) focuses 3. Student: Jody Monks Date: 03. & increase pt commitment. 3. Establish a therapeutic relationship w/PT (R) eases client 1.e. Evaluation: Client's physical activities have increased between physician visits.. shows interest in & participates in physical activities in one week. You need to use professional references when citing sources. i. Patient states an understanding of his health situation 2. Patient assists in developing a diet and exercise program attn on pts own situation & helps prioritize needs making change manageable.NURSING CARE PLAN Problem #3: Sedentary Lifestyle R/T lack interest Goal: Outcome: Pt conveys understanding of importance of regular exercise to his over all well being w/in 3 days. Patient states he is comfortable conversing with the nurse communication and honesty 2.
Key Problem # Supporting Data: Concept Map Name: _______________________________ Date: ________________________________ Key Problem # Supporting Data: Reason for Needing Health Care: Medical Diagnosi/Surgical Pocedure Weakness COPD/Wea kness Key Assessment Key Problem # Supporting Data: See head to toe. Key Problem # Supporting Data: Overall long term outcome: Evaluation: . info won't fit.
Mosby's Dictionary of Medical Nursing & Health Professions (8th ed. (1990).. Mosby Company Digiulio. Heitkemper. Jim (2010).. Medical Surgical Nursing Demystified: A Self Teaching Guide.13. Patient states that his overall mood is "good.). Patient's muscle strength is a +3. Nursing Laboratory & Diagnostics Tests Demystified: A Self Teaching Guide. with a full ROM in all extremities. Camera. New York: Mcgraw-Hill Louis.V. Bucher.REFERENCES Ackley. lower section. New York: Mcgraw-Hill Keogh. (2011). it is however escaping me). 8th ed.12 . Medical Surgical Nursing: Assessment and Management of Clinical Problems." and that his moods have been "normal and stable" for "more than a year. Patients pulses are present and equal in all 4 extremities at +3. Head to Toe Continued. Jackson. Patient has an IV in the right. IV site is CDI. (2007). TOP-side of the forearm (I'm sure there is better wording for that IV description." Student Name: Jody Monks Date: 03. Betty J.. St Louis: C. Keogh.
Diagnostics.12 Date: _________________ Section of Care Plan Head to Toe Assessment Spiritual & cultural assessment Comments 1 3 3 Date: .CLINICAL PAPERWORK GRADING TOOL Clinical Paperwork & Nursing Plan of Care Grading Criteria Jody Monks Student:____________________________________ Possible Points 3 1 2 Medical Pathophysiology 1 Complications (3) Signs & symptoms of complications Interventions to prevent complications Erickson's Developmental stage with Assessment criteria Lab. and Procedure Data Medications 3 Final Concept Map Nursing diagnoses complete (4) Supporting data for nursing diagnoses Goals (one for each nursing diagnosis) Outcomes (one for each goal and one overall long term) Nursing Interventions Rationale for intervention complete w/ source cited Client responses to interventions Evaluation of outcomes completed References in APA format Total Points Instructor Grading/Comments: 4 2 2 4 6 3 4 4 2 50 1 1 Earne d Points 03.13.