Description
In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:
Health Assessment, Health History, and Nursing Diagnosis
- A brief medical/health history
- Summary of laboratory diagnostic results related to the illness/condition and what they mean
- Summary of a head to toe physical assessment
- Your nursing diagnosis
Explanation & Answer
Answer posted please confirm.Kindly go through the work and let me know if you need anything rectified or if a certain requirement has not been met
Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14
Weekly Concept Focus
1)
2)
3)
4)
5)
6)
7)
Mobility or Safety
Elimination
Oxygenation: Gas Exchange
Thermoregulation or fluid and electrolytes
Inflammation/infection
Tissue Integrity
Pain
Date:
Clinical Site
Instructor:
Overweight/underwei
ght:
Marital
Status:
Cultural
Background:
Diet/Nutriti
on:
Treatment
s:
Interdisciplinary
Cares
(OT/PT/RT):
Dressings/Wounds:
(type & location)
Oxygen:
(delivery method &
amount)
Student
name:
Clinical
Site/Unit:
Clinical Site
Mentor:
Allergie
s:
Religion:
Primary
Language:
Code
status:
Activity
:
IV/Tubes/Ostomie
s:
Dialysis
:
1
Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14
Measles
Patient reports experiencing high
sensitivity to light, dry hacking
cough, general body aches, runny
Admitting Medical Diagnosis(s):
nose, and watery eyes. The patient
reported the symptoms for about
eleven days (Nordqvist, 2017).
Hearing problems
Patient’s reports from other clinics
Primary (if different than
show existence of hearing problems
Admitting)
for a period of five years.
Malaria
Secondary
(Do not include History Of):
2
3 nursing interventions:
1. will encourage the
patient to go to outdoor
activities
2. will tell the patient to
avoid being alone
3. will consoul the
client that the disease is
normal
Evaluation:
This will ensure
client stays
positive
Rasmussen College
NU231LL Professional Nursing
Clinical Worksheet Revds. 10/8/14
Diagnosis: risk for facing
depression issues
Evaluation: The
strategy will
help the client
stay free from
other infections
3 nursing interventions:
1. will educate client on
the importance of
staying fully covered
2. will tell the client to
apply his medication
frequently
3. will tell the client to
maintain hygene
Outcome: disease
affects the ear and
its organs
Outcome: Isolation
Diagnosis: risk for losing
hearing abilities
Outcome: through
the skin open
wounds
Evaluation:
This will ensure
client’s ears are
active
Evaluation:
This will aid
with complete
reduction of the
abdominal
pains
Nursing Care Plan
Henry Cork
Diagnosis: risk for getting
other diseases due to open
wounds
3 nursing interventions:
1. will inform the client
to always apply
medication to the ears
2. will inform the client
to ensure his ears are
active
3. will inform to
participate in social
activitie
Diagnosis: risk for getting
abdominal pains
3 nursing interventions:
1. will advise client to
stay active
2. will inform the client
to take a lot of water
3. will educate client to
eat well
Outcome: Vomiting
and diarrhea
3
Rasmussen College
NU231LL Pr...