Nursing Care Plan and Evaluation

Instructions 1. The nursing care plan evaluation is based upon the application of criteria appropriate for the students skill set. 2.All nursing care plans must(prenominal) be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard in each clinical course. 3. The place rubric must be attached last page of nursing care plan. 4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden beat Assessment, Fall Risk) must be attached.HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be wakeful about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have aut hority, the best course of action is to refer that idiosyncratic to the appropriate administrative personnel.IVY TECH COMMUNITY COLLEGE OF INDIANA REGION 6 NURSING PROGRAMNURSING HISTORY & PHYSICAL ASSESSMENT FORMStudent _________________________ Date of Care __1-26-2010 to 1-27______ Facility/whole _Oncology_BMH___ InstructorHealth HistoryBiographical DataPatients Initials _DH___ Age __79__ Gender__F__ Martial military position Widow__ DOB _7/29/1930__________Birthplace Randolph County__ Ethnic origin/Race _Caucasian_ Occupation previous factory worker_Work status retired_________ Educational background __High school______________History commencement initials ___Pt__ Relationship to client __self__________________Transcultural Considerations (Time, space, touch, & value orientation, language considerations, spiritual beliefs, education level)Pt speaks English. High school was the highest education received. She worked at a factory for years and then lay off to stay home and r aise her two kids.Special NeedsWalkerReasons for Seeking Care (Brief statement in patients words that describes reason for visit Chief Complaint) Pt states she is hither due to her ovarian cancer.Past Health HistoryApproximate hospitalization dates 1/17/2010Serious or Chronic Illnesses (Approximate onset) Pt has a hx of HTN, gallbladder disease, hiatal hernia, ulcers, diabetes type 2, hypothyroidism, depression, ovarian cancer, arthritis, migraines, cataracts and a business leg fx. Pt has also had these surgeries hysterectomy, appendectomy, cataracts, cholecystectomy, colon resection, hernia, thyroidectomy, tonsillectomy, and adenoidectomy.Obstetric RotationCurrent Obstetric AssessmentGravidity ______ Term ______ Preterm ______ Abortions ______ Living ______Blood eccentric person _____ Rh Factor _____LMP _______ EDC _______ RhoGAM position ______ DTR ________ (if applicable)Date & Time of Delivery __________________________________Type of Delivery ___ SVD ___ Forceps ____ Vacuum ____ Cesarean Section___________ Anesthesia/Analgesia _______ EBLPerineum ______ Intact ______ Episiotomy _____ Laceration & Location__________________Please note any current obstetric problems/complications (GDM, pre-eclampsia, etc.)Please note any past obstetrical problems/complications (Condition, duration, treatment)Infant DataGender ___________Apgar Score ___ / ___ Gestational Age _____weeks Cord Vessels_____ Feeding method ______ Weight at Birth _______ Length at Birth ________Blood Type & Rh ______ Direct Coombs ________ (if known)Complications at DeliveryAttachment BehaviorsAllergies Medications _Vaseline, Tetanus, Penicillin, Codeine, Aspirin, Morphine, Sulfa ___________ What mannequin of reaction was experienced __Rash, hives, facial swelling, Headache, _______ Foods ___NA________________________________________________________________ What kind of reaction was experienced_Na_________________________________________ Contact __NA__________________________________________ ______________________What kind of reaction was experienced__NA________________________________________Current Home Medications (all prescription, over the counter, home and herbal remedies, include trade or generic name, dose, and frequency) Reason for taking medication (patient stated). 1. Lisinopril 20 mg 1 pad of paper q pm daily- lowers BP2. Levothyroxine 100 mcg 1 tab qdsync daily- thyroid replacement 3. Ondansetron IV 4-8 mg q6hr or PRN- unwellness med 4. Sennosides 8.6 mg 1 tab daily- for constipation 5. Polyethylene glycol 17 gr powder daily take with 8 oz of water- for constipation 6. Demecloclycline 300 mg 1 tab TID- tx of bacteria 7. Nystatin 5 mL QID swish and spit- tx of fungus 8. Insulin Reg (Human) PRN with sliding scale- for diabetes 9. Promethazine 12.5 +5mL q8hr dilute with 9mL NS prior to IV with max rate 25mg/min helps with nausea and used for antihistamine 10. Hydromorphine brand Dilaudid 2 mg q2hr or PRN- per painSubstance use (Frequency and amount) Tobacco ___Past hx for 40+ years _________ Alcohol ___hx of occasional ____________________________________________ Illicit drugs __none____________________________________________________________Family History (Health status or cause of death of blood relatives displayed in a genogram format)Family & Social Support Systems Pt has a daughter and son that visit her daily. She also has a granddaughter that visits a few times.Physical AssessmentPrimary Medical Diagnosis _______Hyposmality___________________________________________________________________ Secondary Medical Diagnoses __Ovarian Ca Height __55______ Weight ___182_____ Head Circumference (if 2 yrs of age) _________________ 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 fluid restriction____Consumption % __less than 10% General AppearancePt is a 79 year old female with gray hair. She is sitting up on the BS C with a perch behind her back and a pillow in her hands pressing against her abd. Breakfast tray is sitting in front of her but she is unwilling to eat. Pt states she just hurts so bad from the constipation. Pain meds had already been given to her.Patients Health Promotion Activities At Home Pt uses a walker at home.Site Assessment of Invasive Lines and Drainage Tubes (Note location, type, and findings) PICC line in right upper chest with no signs of redness or bruising. There is an IV in her upper right arm that has some bruising.Mental Status General thought (attach screening tool/results if used) A & O X3. Pt sometimes seems to be a little confused.Skin, sensory hair & Nails Braden Scale Score ___19 LOW _______ (attached) Skin is warmly/dry/intact. Pt has a bruise over her left antecubital area and on top of left hand due to a previous IV. She has a scar from her gallbladder surgery that is still healing with no signs of infection. She also has an appendectomy scar from a p revious surgery years ago. Hair is full and thick. Nails of both upper and lower extremities are yellow with cap refill.