Nursing Care Plan and Evaluation Free Essays

Directions: 1. The nursing care plan assessment depends on the utilization of standards suitable for the student’s range of abilities. 2. We will compose a custom exposition test on Nursing Care Plan and Evaluation or then again any comparative theme just for you Request Now All nursing care plans must be composed (Times New Roman, 12 point textual style). The nursing care plan structure is accessible on Blackboardâ„ ¢ in each clinical course. 3. The evaluating rubric must be appended †last page of nursing care plan. 4. All applicable appraisal instruments utilized (physical, mental, or mental for example Braden Skin Assessment, Fall Risk) must be joined. HIPAA (Health Information Privacy and Protection Act) commands all medicinal services suppliers secure patient protection. Just data that the patient explicitly discharges might be imparted to other people. Just expert people (understudies and teachers) associated with care are permitted access to the social insurance data. The understudy ought to be mindful about what data is shared verbally and with whom. In the event that the understudy is drawn nearer for quiet data by somebody who implies to have authority, the best game-plan is to allude that person to the suitable managerial staff. IVY TECH COMMUNITY COLLEGE OF INDIANA †REGION 6 NURSING PROGRAM NURSING HISTORY PHYSICAL ASSESSMENT FORM Understudy _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit _Oncology_BMH___ Instructor Wellbeing History Anecdotal Data: Patient’s Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________ Origination: Randolph County__ Ethnic starting point/Race: _Caucasian_ Occupation: past industrial facility worker_ Work status : retired_________ Educational foundation __High school______________ History source initials ___Pt__ Relationship to customer __self__________________ Transcultural Considerations: (Time, space, contact, esteem direction, language contemplations, otherworldly convictions, instruction level) Pt communicates in English. Secondary school was the most elevated instruction got. She worked at an industrial facility for a considerable length of time and afterward quit to remain at home and bring up her two children. Uncommon Needs: Walker Purposes behind Seeking Care: (Brief explanation in patient’s words that depicts purpose behind visit †Chief Complaint) Pt states she is here because of her ovarian malignant growth. Past Health History: Rough hospitalization dates: 1/17/2010 Genuine or Chronic Illnesses (Approximate beginning): Pt has a hx of: HTN, gallbladder sickness, hiatal hernia, ulcers, diabetes type 2, hypothyroidism, despondency, ovarian malignancy, joint inflammation, headaches, waterfalls and a correct leg fx. Pt has additionally had these medical procedures: hysterectomy, appendectomy, waterfalls, cholecystectomy, colon resection, hernia, thyroidectomy, tonsillectomy, and adenoidectomy. Obstetric Rotation Current Obstetric Assessment: Gravidity ______ Term ______ Preterm ______ Abortions ______ Living ______ Blood classification _____ Rh Factor _____ LMP _______ EDC _______ RhoGAM Status ______ DTR ________ (if pertinent) Date Time of Delivery __________________________________ Kind of Delivery ___ SVD ___ Forceps ____ Vacuum ____ Cesarean Section ___________ Anesthesia/Analgesia _______ EBL Perineum: ______ Intact ______ Episiotomy _____ Laceration Location__________________ If you don't mind note any current obstetrical issues/complexities (GDM, pre-eclampsia, and so forth.) If you don't mind note any past obstetrical issues/complexities: (Condition, term, treatment) Newborn child Data: Sexual orientation ___________Apgar Score ___/___ Gestational Age _____weeks Cord Vessels_____ Taking care of technique ______ Weight at Birth _______ Length at Birth ________ Blood classification Rh ______ Direct Coombs ________ (whenever known) Intricacies at Delivery: Connection Behaviors: Sensitivities: Meds: _Vaseline, Tetanus, Penicillin, Codeine, Aspirin, Morphine, Sulfa ___________ What sort of response was experienced: __Rash, hives, facial growing, Headache, _______ Nourishments: ___NA________________________________________________________________ What sort of response was experienced:_Na_________________________________________ Contact: __NA________________________________________________________________ What sort of response was experienced:__NA________________________________________ Current Home Medications: (all solution, over the counter, home and home grown cures, incorporate exchange or conventional name, portion, and recurrence) Reason for taking drug (understanding expressed). 1. Lisinopril 20 mg 1 tab q pm every day brings down BP 2. Levothyroxine 100 mcg 1 tab qdsync every day thyroid substitution 3. Ondansetron IV 4-8 mg q6hr or PRN-sickness drug 4. Sennosides 8.6 mg 1 tab every day for blockage 5. Polyethylene glycol 17 gr powder every day take with 8 oz of water-for blockage 6. Demecloclycline 300 mg 1 tab TID-tx of microbes 7. Nystatin 5 mL QID wash and spit-tx of organism 8. Insulin Reg (Human) PRN with sliding scale-for diabetes 9. Promethazine 12.5 +5mL q8hr weaken with 9mL NS preceding IV with max rate 25mg/min †assists with sickness and utilized for antihistamine 10. Hydromorphine brand: Dilaudid 2 mg q2hr or PRN-per torment Substance use: (Frequency and sum) Tobacco ___Past hx for 40+ years _________ Liquor ___hx of periodic ____________________________________________ Illegal medications __none____________________________________________________________ Family ancestry: (Health status or reason for death of blood family members showed in a genogram group) Family Social Support Systems: Pt has a little girl and child that visit her day by day. She additionally has a granddaughter that visits a couple of times. Physical Assessment Essential Medical Diagnosis: _______Hyposmality___________________________________________________________________ Secondary Medical Diagnoses: __Ovarian Ca Stature __5’5†______ Weight ___182_____ Head Circumference (if 2 yrs old enough) _________________ TPR _98.5 †66 †28_____ B/P __142/77____ Pain Score ___10___Pain Goal __0___ BMI ___30_______ Oxygen Saturation _92____ Supplemental Oxygen _2L___ Diet: __general with 1500 ml liquid restriction____Consumption % __less than 10% General Appearance: Pt is a multi year old female with silver hair. She is sitting up on the BSC with a cushion despite her good faith and a pad in her grasp squeezing against her abd. Breakfast plate is sitting before her yet she is reluctant to eat. Pt states she â€Å"just harms so terrible from the constipation.† Pain drugs had just been given to her. Patient’s Health Promotion Activities At Home: Pt utilizes a walker at home. Site Assessment of Invasive Lines and Drainage Tubes: (Note area, type, and discoveries) PICC line in right upper chest without any indications of redness or wounding. There is an IV in her upper right arm that makes them wound. Mental Status †General Impression: (append screening apparatus/results whenever utilized) An O X3. Pt in some cases is by all accounts somewhat befuddled. Skin, Hair Nails: Braden Scale Score: ___19 LOW _______ (appended) Skin is warm/dry/unblemished. Pt has a wound over her left antecubital zone and on left hand because of a past IV. She has a scar from her gallbladder medical procedure that is as yet mending without any indications of disease. She likewise has an appendectomy scar from a past medical procedure years back. Hair is full and thick. Nails of both upper and lower limits are yellow with top off. Instructions to refer to Nursing Care Plan and Evaluation, Papers