Nursing care plan

Anonymous
timer Asked: Dec 7th, 2018
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Question description

The template needs to be filled out based on the scenario. Example given. All the requirments needs to be filled out determining a care plan for the patient.

Tutor Answer

Knutsen
School: UC Berkeley

Attached.

Running head: NURSING CARE PLAN1

Nursing Care Plan

Student’s Name
Institution Affiliation

NURSING CARE PLAN2

Student
Instructor
Patient
F.N
Initial
Code Status
Penicillin and Cashews
Allergies
Temp (C/F Site)
99

Date 11/20/2018
Course Nurse 101L
Unit/
Room#

Pulse (Site)
116

DOB

1938
Height/Weight 125Lbs/ 62”
Final EDC/Current Gestational
Age:

Respiration
24

Pulse Ox (O2 Sat)
92%

History of Present Illness including Admission Diagnosis & Chief
Complaint (normal & abnormal) supported with evidence based citations

Chief Complaint (if possible, use patients words):
A 80-year visits the hospital due to the injuries resulting from an unwitnessed fall at her home: “I tripped over my cat and fell on my left side”.
HPI (PQRST of chief complaint, along with other pertinent pregnant
complications [if any]): ___ y.o. at ___ week’s gestation, arrives to the
hospital with prior noted chief complaint.
Blood pressure 130/80
Pulse rate 116
Respiration Rate 24
Oxygen saturation 92%
Body temperature 99 degrees F
Height 62
Weight 125 pounds
Abnormal
Pulse rate
Respiration rate
Oxygen saturation

Blood Pressure
130/80

Pain Scale 1-10
9/10

Physical Assessment Findings including presenting signs and
symptoms supported with Evidence Based Citations. If on
postpartum, BUBBLE-HE for maternal assessment and if on
antepartum/intrapartum, the following apply: fundal height,
CV/Thorax, perineum, SVE, and fetal heart rate Category.
A. Inspection
Inspection involves a situation where a medical practitioner checks
the certain body parts of the patient for their normal shape,
consistency, and color. Some of the findings resulting from the
inspection of some part of the body may make the practitioner to
extend the focus on other parts of the body. For instance, swollen
legs may make the health practitioner o focus on the factors that
cause the swelling of legs such as the injuries, fracture, and the
extra fluid in the legs of a person caused by his or her heart. Some
of the commonly inspected areas are:
1. Skin on the basis of cuts, bruises, and lumps among others
2. Eyes and face to see if they are normal and even
3. Legs to check whether they have any swelling complications
4. Joints and Elbows for complications such as inflammation and
swelling.
B. Palpation
Palpation happens when the physical examiner makes use of his or
her hands to feel for any form of physical abnormality of the patient

NURSING CARE PLAN3

Normal
Blood pressure
Body temperature
(Crisafulli& Torres, 2018)
Admit Dx:
Crackles on auscultation on the lower left lobe (abnormal)
Left thigh and left hip pain 9/10 (abnormal)
Visible injuries of size 3*3” on the lateral left thigh of the patient but no
open wound (abnormal)
Swelling on the ankles (normal)
Urinating difficulties (abnormal)
Mildly incontinent (normal)

during their assessment. The examiner concludes on the
abnormalities suffered by the patient following the findings that are
made from either the abdomen, chest wall, or lymph nodes of the
patients among others. The findings provide clues to more
diagnosis. The palpation helps to determine the presence of lumps
or masses in any of the body parts.
C. Percussion
Percussion happens when a physical examiner ...

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Review

Anonymous
Goes above and beyond expectations !

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