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Fundamentals of Nursing Nursing Process Care Plan

Fundamentals of Nursing Nursing Process Care Plan

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NURSING PROCESS CAREPLAN STUDENT NAME: MEDICAL PREP INSTITUTE OF TAMPA BAY COURSE NAME: INSTRUCTOR: ASSIGNMENT DATE: MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan Client Initials: Culture/Ethnicity: Support System: Unit: Room/Bed: Religion: Occupation: Age: Sex: Language: Current Work Status: Weight: Height: Marital Status: Highest Grade Completed: Primary Patient Complaint: Patient Medical History: Diagnostic Procedures (Not to include labs): Surgical Procedures: Pathophysiology/Etiology (Theory): Define patient Supporting Symptomatology: What patient data supports your selection Developmental Stage (Theory): Utilize Erikson. Identify Developmental Stage (Actual): Identify what developmental stage your primary problem and cause(s). what stage is applicable to your patient based on their age. Vital Signs/Frequency: of Pathophysiology? patient is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage.Fundamentals of Nursing Nursing Process Care Plan
LAB RESULTS INTERPRETATION PATIENT’S LAB RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS DIAGNOSTIC RESULTS INTERPRETATION PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #1 (Physical) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #2 (Physical) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) ASSESSMENT Subjective/ Objective NURSING DIAGNOSIS #3 (Psychosocial) PLANNING/ OUTCOME (Client Centered) 1 Short Term 1 Long Term INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal RATIONALE FOR INTERVENTIONS 1 per Intervention EVALUATION (Evaluate each Goal) STUDENT NAME: Medication #1: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #2: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication) Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #3: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #4: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Routes: Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication) Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: STUDENT NAME: Medication #5: Classification of Medication: Trade Name: Generic Name: Dosage: Dosage Forms: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: Routes: MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan References Page 1. 2. 3. MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan GRADING RUBRIC Student Name: _____________________________________________ Category Excellent 1 Point GRADE: /9 Course Name: ______________________________________________ Good 0.75 Points Fair 0.50 Points Poor / Incomplete 0.25 Pts – 0 Pts Accurate and thorough Pt. demographic Patient Demographic Pg: Pt. Patient Demographic Page Patient Demographic Page is is incomplete, PATIENT DEMOGRAPHIC PAGE Primary Complaint, Medical is included, but missing one included, but missing several missing or Hx, Dx Proc, Surgical Proc., element. elements. inappropriate to Pathophys., Devel Stage, etc. patient. Contains adequate number Labs & Does not contain adequate Includes complete labs and of Labs/Diagnostics related Diagnostics number of Labs/ Diagnostics LABS & DIAGNOSTICS diagnostics sheet related to to & appropriate to portion is related to & appropriate to Includes labs and diagnostics appropriate to & appropriate to patient’s patient’s disease process, incomplete, patient’s disease process, and patient & patient’s disease process disease process: specific, & but labs & diagnostics may missing or may not be specific, labeled correctly labeled. not be specific or correctly inappropriate to or listed with rationales.Fundamentals of Nursing Nursing Process Care Plan
labeled. patient. Assessment Includes all pertinent data Includes all pertinent data Does not include all pertinent ASSESSMENT portion is related to nursing diagnosis related to nursing data related to nursing Includes subjective, objective and historical incomplete, and does not include data diagnosis, but also includes diagnosis. May also include data that support actual or risk for nursing missing or that is not related to data not related to nursing data that does not relate to diagnosis. inappropriate to nursing diagnosis. diagnosis. nursing diagnosis. patient. DIAGNOSIS Diagnosis is appropriate for Diagnosis is appropriate for Diagnosis is not appropriate Diagnosis Includes the most appropriate diagnosis for patient and ordinal level, patient and ordinal level, for patient and ordinal level portion is patient and ordinal number that includes all and diagnosis is NANDA and diagnosis is NANDA (first diagnosis, second incomplete, appropriate parts (stem, related to or R/T, approved. Diagnosis also approved, but does not diagnosis, etc.). May also not missing or and as evidenced by AEB for actual includes all parts and include all parts or be NANDA and may not inappropriate to diagnosis) and is NANDA approved.
information is listed in information is listed in include all parts. patient. (2 Physical & 1 Psychosocial) correct part of diagnosis. wrong part of diagnosis. PLANNING (Goal Setting) Goal statement is patient or Goal statement is patient or Goal statement is not patient Goal portion is Includes a patient or family goal that is most family oriented, and family oriented, and or family oriented and may incomplete, appropriate for the patient/family and the contains two measurable contains at least one not have measurable and/ or missing or nursing diagnosis. Goal should be realistic measurable and realistic realistic criteria or a target inappropriate to and measurable by at least two criteria and realistic criteria and a criteria or a target date or time. patient. target date or time. and have a target date or time. date/time. Interventions portion contains adequate number IMPLEMENTATION (Interventions) of interventions to help Interventions portion Interventions portion does Includes 3 interventions or nursing actions Interventions patient/family meet goal, contains adequate number not include adequate number that directly relate to the patient’s goal, that portion is and interventions are of interventions to help of interventions to help are specific in action and frequency, consist incomplete, specific in action and patient/family meet goal, patient/family meet goal. of 1 monitoring, 1 action and 1 teaching missing or frequency, consist of 1 but interventions may not Interventions may also not intervention. Interventions should be inappropriate to monitoring, 1 action and 1 be specific, labeled or listed be specific, labeled or listed appropriate to help patient or family meet patient. teaching intervention and with appropriate rationales. with appropriate rationales. their goal. are listed with appropriate rationales. Evaluation portion does Evaluation portion does Evaluation portion does not EVALUATION contain data that is listed as contain data that is listed as contain data that is listed as Evaluations Includes data that is listed as criteria in goal criteria in goal statement. criteria in goal statement, criteria in goal statement. portion is statement. Based on this data, goal is Does describe goal as met, but does not describe goal May also not describe goal as incomplete, determined to be met, partially met, or not partially met, or not met. If as met, partially met, or not met, partially met, or not missing or met. If goal was not met or partially met, goal was partially met or met. May also not include met. May also not include inappropriate to plan of care is revised or continued and a not met, includes revision revision or new evaluation revision or new evaluation patient. new evaluation date/time is set. and/or new evaluation date/time. date/time. date/time. Includes 5 or more drug DRUG CARDS Includes at least 4 drug Includes at least 3 drug cards Drug Cards are cards related to and Includes at least 5 drug cards appropriate cards related to patient’s related to patient’s disease incomplete or appropriate to patient’s to patient, complete and accurately selected. disease process. process. missing. disease process. Additional Criteria: (Total 1 point) ⃝ Paper is Typed. ⃝ Spelling Correct. ⃝ Neat. ⃝ At least 3 References in proper APA Format. Case Study for Care Plan Assignment: A retired 69-year-old man “Mr. Casey” with a 5-year history of type 2 diabetes. Although he was diagnosed 5 years ago he had symptoms indicating hyperglycemia for 2 years before diagnosis. His fasting blood glucose values of 118–127 mg/dl, which was explained to him as “borderline diabetes.” He also states he has had past episodes of nocturia with large pasta meals and Italian pastries. At the time of diagnosis, he was advised to lose 10 lbs. Referred by his family physician to the diabetes clinic, Mr. Casey presented with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon. Mr. Casey also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia.
He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken OTC medications to try to control his diabetes. He stopped these supplements when he did not see any positive results. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. Mr. Casey states that he has “never been sick a day in his life.” He is retired and volunteers locally. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, Mr. Casey has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies. During the past year, Mr. Casey has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose. Mr. Casey’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago.Fundamentals of Nursing Nursing Process Care Plan
The medical documents that Mr. Casey brings to his appointment indicate that his hemoglobin A1c(A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. Mr. Casey has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care.
However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years. Physical Exam A physical examination reveals the following: • Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2 • Fasting capillary glucose: 166 mg/dl • Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg • Pulse: 88 bpm; respirations 20 per minute • Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy • Thyroid: nonpalpable • Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops • Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally • Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle Lab Results Results of laboratory tests (drawn 5 days before the office visit) are as follows: • Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl) • Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl) • Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl) • Sodium: 141 mg/dl (normal range: 135–146 mg/dl) • Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl) • Lipid panel • Total cholesterol: 162 mg/dl (normal: <200 mg/dl) • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl) • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl) • Triglycerides: 177 mg/dl (normal: <150 mg/dl) • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0) • AST: 14 IU/l (normal: 0–40 IU/l) • ALT: 19 IU/l (normal: 5–40 IU/l) • Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l) • A1C: 8.1% (normal: 4–6%) • Urine microalbumin: 45 mg (normal: <30 mg) Please use the attached Care Plan outline for this assignment and post in the “Drop Box” under “Instructional”. Credit of care study to: Geralyn Spollett, MSN, C-ANP, CDE Reference: American Diabetes Association. (2003, January 1). Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Retrieved from http://spectrum.diabetesjournals.org/content/16/1/32 .