...Nursing Care Plan Mohave Community College Nur 122. Nursing 2 November 8, 2011 MOHAVE COMMUNITY COLLEGE NURSING DEPARTMENT NURSING CARE PLAN NUR 122 ASSESSMENT A. ADMISSION DATA Date of admission 10/07/11 Client initials CW Medical diagnosis COPD/Leukocytosis Age 65 Sex Female Marital Status Divorced Ethnicity Caucasian Religion Catholic Vital signs upon admission: B/P 107/61 P 98 R 20 T 97.6 Ht 5’4 Wt 99.9lbs Allergies C.W. is allergic to ASA, it causes her to have an upset stomach. B. HEALTH-ILLNESS TRANSITION History of present illness C.W. is a 65 year old female with a history of COPD. She has been admitted to the hospital on several different occasions for a COPD exacerbation. C.W. was admitted through the ER on October 7, 2011 for an increased cough, shortness of breath, which got progressively worse with chest tightness. C.W.’s most recent hospitalization was on September 13, 2011 for a pneumothorax. She was also admitted sometime in August for a COPD exacerbation. Significant client health history (include family history) C.W. is a 65 year old female who lives with her ex-husband. She has a history of leukocytosis, anemia, hyponatremia, COPD, valley fever, chronic pain syndrome, back pain, osteoporosis, small-bowel obstruction, peripheral neuropathy, constipation, and pneumothorax. C.W. also admits to being a current smoker. She smokes approximately 1½ packs per day....
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...NURSING PROCESS PAPER Student Name: Date of Care: 10/14/09 Date of Admission: 10/10/09 I. HEALTH STATUS | Admitting Dx: COPD Exac/Chest Pain | Pt. Init.D.R | Rm No.353 | Age60 | SexM | RaceCaucasion | ReligionCatholic | OccupationDisabled | Surgery: Medical Treatment: Back Surgery/ Coronary Artery Bypass Grafting COPD Exac/Chest Pain | Chief Complaint/Reason for Hospitalization & Hx. of Present Illness (with 1-8 critical characteristics, Jarvis pg. 85) Chest Pain | | 1.Location: Midsternal chest pain radiating to left arm. 2. Quality/characteristics: Squeezing, tightening, felt like chest was going to explode. 3. Quantity: 8 on a scale from 1-10 4. Setting: at rest 5. Associative factors: SOB and nausea 6. Aggravating/relieving factors: Aggravated by activity, unable to relieve in any position 7. Timing (Onset, duration, frequency): Sudden and constant pain 8. Patient perception: Thought he was having a heart attack. | Other illness or conditions & year of onset. | | AllergiesNKA | COPD- 2004 Deep Vein Thrombosis -2002Anxiety-2000Depression-1998Lumbar/Cervical Spondylosis-1982HTN- 19XX-Patient cannot recall exact year | | Immediate Teaching Needs | | Hospital safety- Reminded patient to call for assistance, call light within reach, non skid footwear for reduction of falls. Talked with patient regarding fall safety. Teach non-pharmachological...
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...have learned so far, but who ultimately helped me realize that I can and will became a great nurse in the near future. My clinical experience has been taking place at Presbyterian Hospital, thus far I have really enjoyed my time there. My clinical instructor has been extremely positive, helpful and encouraging. While I have been there I have encountered a couple of patients that have left an impression, but there was one particular patient that tested all the knowledge I have learned so far and required me to use all my personal skills to use in order to build a trusting relationship with her. I was assigned to a patient that I would work with for the majority of the day, and I would also have to complete my care plan on this particular patient. The Nursing care plan requires a combination of subject and objective data, it is a long questionnaire that requires the participating patient to disclose Page 2 a lot of personal information. Having this in mind, I knew that in order to receive the most truthful information I would have to build a...
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...Journal Today I felt like I am not ready for the clinical. I was worried about tomorrow exam and my focus was more on exam then clinical. We had a pre-conference as usual which gives us information on what we are going to focus on while taking care of a client. We discussed about oxygenation and about medication. I was assigned with a client who has pneumonia, seizure disorder, and second degree MVA. Soon I entered the client room I washed my hand, introduce myself, checked client id and started assessing the client which I was lacking before example checked whether the tubing are intact or not. After that I took vital signs which were easier than before. I learnt something new while giving a bath to a client. I learnt to put on the condom catheter to a client with the help of the professor. I was scared while changing the condom catheter since it was my first time but at last I did it. I gained little self-confident after doing it. Changing the bed sheet was challenging one since I have to turn and lift my client. At last we had a post conference where we took some data from the client record and we discussed about what we did so far. We talked about our client and related nursing diagnoses. This conference gives much knowledge and it is really helpful. Two questions: Q1. How would you determine if the client has adequate fluid intake? Q2. What kind of feelings are there when giving a bath to a...
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...Assessment tools are useful for nursing care as they can act as a guideline while trying to assess patients. Finding the right assessment tool to match the nursing care going to be given is important. All assessment tools may not match the type of care going to be given. It is important to evaluate the assessment tool not only to match the care, but also to make sure the tool is thorough and useful. The three assessment tools discussed in this essay are an admission assessment by Pamela Craig, a nursing needs assessment tool by the Department of Health Social Services and Public Safety, and a physical assessment tool by F.A. Davis. The admission assessment by Pamela Craig was designed through evaluation of the previous admission assessment tool in which Pamela Craig redesigned it to fix the flaws of the old one. The tool begins with baseline vitals upon admission, with the inclusion of how the patient was brought to the facility and from where. The tool includes allergies, with a section specific to latex allergies. It includes who the information is obtained from, in case the information is not able to be obtained from the patient. There is a place for family history information, as well as history of past diagnoses for the patient. There is a section for nutrition that includes questions about weight loss, nausea and vomiting, enteral feeding, and changes in appetite. The physical assessment part of the assessment tool covers each system. There are boxes to check within each...
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...Putong, Jonathan 4 y/o Post incision and drainage Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation | Subjective:“ sakit sugat ko dito ma” as verbalized by the patientObjective: * Localized erythema and edema * (+) pruritus on the site of the incision. * (+) Facial grimace * (+)Irritability * (+) Guarding behavior * (+) Crying * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 * Pain assessment>Location: Right post auricular area>Interval: frequent | Acute pain related to tissue trauma secondary to incision and drainage as manifested by * Localized erythema and edema * Pruritus on the site of the incision * Facial grimace * Irritability * Crying * Guarding behavior * Frequent interval of pain | Nociceptive stimuli(wound/inflammation)↓Nerve fibers (nociceptor) ↓ ↓A-delta fiber C-fiber (fast) (slow) ↓ ↓ Spinal cord & Dorsal horn pain modulating circuit (primary touch...
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...While the Registered Nurse, be it ADN or BSN, provides similar care as regards skill level, medicine administration, and composition of care plans, the LVN is more limited in scope. The LVN is not permitted to hang or push IV medications, perform admission assessments, write nursing care plans, or flush PICC/Central lines. Differences between ADN and BSN are often more subtle as regards both learning and application. Bachelor level nurses typically demonstrate a higher level of competency when dealing with patients of greater comorbidity and acuity as well as a more sophisticated approach to decision making. Medical terminology indicates comorbidity as multiple system diagnosis of disease, such as a patient with both acute renal failure and congestive heart failure. Such an individual presents a unique challenge in that blood pressure control is at risk via both systems. While both ADN and BSN may approach the nephrologist regarding use of a diuretic, the BSN will have a superior understanding regarding risks/side-affects as pertains to each system, ideal length of use, and related laboratory results to communicate to each physician specialist. This difference in ability stems, in part, from additional hours exposing them to extensive pathophysiology, pharmacology, and research involving all aspects of the profession. Acuity reflects patient stability and while list of diagnosis, patient history, and physical may contribute a more intimate knowledge of client needs, the...
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...S.S.N.M.M COLLEGE OF NURSING SEMINAR ON UNIT PLAN SUBMITTED TO; SUBMITTED BY; PROF:MRS.SAMPATH ANEESH S P VICEPRINCIPAL 1st yr Msc Nursing SUBMITTED ON: 11.11.2011 INTRODUCTION With in the last two decades , more and more educators have come to accept the unit as the basis of organization of learning. They recognize the facts that learning in units more effectively meets the needs of the students than traditionally daily lesson-assigning and lesson learning procedure. The concept of unit learning is still in the stage of development. Consequently , it has come to mean different things to different teachers . the situation has caused the evolution of various names which are used to differentiate between the several interpretations ,such as contract plan , Dalton plan ,project method , unit assignment ,Winnetka plan and others . The basis of unit idea can be traced to JOHANN FRIEDRICH HERBART (1776-1841) . herbart stressed 4 essentials in learning process 1. Clear apprehension by the student of each individual fact . 2. Association or comparison of the facts. 3. Systematization...
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...Heritage Assessment Paul Bockoven Grand Canyon University NRS429-V October 14, 2012 Heritage Assessment Cultural assessments can be useful tools for a registered nurse to develop adequate plans of care, especially when it comes to education. They have limits however, as not every individual within a certain cultural ‘category’ can be expected to conform the way their heritage may dictate. Assigning a score to any person to predict how they may act, or learn, is contrary to the direction nursing care plans in general have taken. With that in mind, there is some value to using tools like the heritage assessment as a baseline, or starting point. The problem arises because of this particular tool being used to generalize instead of individualize. Developing a sense of a person’s cultural heritage and assigning an ambiguous score has no real meaning when the focus of a care plan is not supposed to take into account anything that is not directly related to the individual for whom it is being tailored. Standards clearly state that the assessment, planning and delivery of a person's care must be centered on the individual, and developed with them or their significant others (Rollin, 2011, p. 541). A person filling out the heritage assessment may, in fact, not adhere to or agree with it’s findings, may not understand it’s significance and as such, this tool could actually lead a caregiver in the wrong direction. The idea that any person who, according to this tool, identifies...
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...on your results from the Nursing Expertise Self-Report Scale and explain how you plan to use this information to improve your communication skills in health care settings. The Nursing Expertise Self-Report Scale and Reflection was an interesting assessment on my nursing skills. The questions that were asked in the scale were difficult to answer based on the grading scale. Overall it was a good reflection of how I approached my patients and utilized my skills. After completing the nursing scale, I realize that there are some things that I need to do different. For example, question number six mentioned, “Emotional attachment to get in the way of good care.” (Hansten, 2009, pp. 175-176) I feel that is a question that is difficult to answer because a nurse needs to have an emotional attachment to connect. The reason we became nurses is because we care for others and we want to care for their health. We came into this field with an emotional attachment. I will continue to treat my patients how I would like to be treated and show them the respect they deserve being under my care. Every nurse is different in how they treat and care for our patients. We all have procedures and guidelines to follow by as a health care professional, but we use our own instincts in other areas of care. Another question that came to mind was question number three. It states, “Quality nursing care results from strictly adhering to policy and procedure.” (Hansten, 2009, pp....
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...Dorothy Johnson - Nursing Theorist Biography and Career of Dorothy E. Johnson Dorothy E. Johnson was born on August 21, 1919 in Savannah, Georgia. She earned her Bachelor of Science in Nursing in 1942 from Vanderbilt University in Nashville, Tennessee. In 1948, she received her Master's degree from Harvard University. During her career, Johnson was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles. She retired in 1978. Dorothy Johnson Works written by Dorothy Johnson include: Theory Development: What, Why, How? Barriers and Hazards in Counseling Dorothy Johnson's Contribution to Nursing: Behavior System Model Johnson is known for her Behavior System Model of Nursing, which was first proposed in 1968. The model advocates the fostering of efficient and effective behavioral functioning in the patient to prevent illness. The patient is defined as a behavioral system composed of seven behavioral subsystems. Each subsystem is comprised of four structural characteristics. An imbalance in each system results in disequilibrium. The nurse's role is to help the patient maintain his or her equilibrium. Johnson's theory of nursing defines nursing as "an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an optimum level under those conditions in which the behavior constitutes a threat to the physical...
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...upper arms. P.R. is able to move his shoulders to slightly lift his arms, but has no movements in his legs or the trunk. P.R. requires total assistance for all activities of daily living, and is incontinent of both bowel and bladder function. He speaks primarily Spanish and cannot communicate in English. He is verbally abusive and becomes combative with care givers. He does not have family support in America and is having difficulty adapting to American foods. P.R. has stage III ulcers on each of his buttocks, with various bruises on his lower forearms from trying to attack the faculty personnel. Both feet are starting to turn downward, indicating plantar flexion contractures. The purpose of this paper is to demonstrate the issues that are involved in nursing care, based on Maslow’s hierarchy of needs. This includes physiological, psychological, safety, and social concerns. An example of a complete nursing care plan will be provided for each category of needs identified in P.R’s case study. Patient Care Issues General Spinal cord injuries to an individual present with multiple areas of concerns to nursing care providers. Physiological issues are first addressed when the patient arrives in the emergency room to stabilize the patient according to the airway, breathing, and circulation. Then, spinal cord injury will lead to loss of motor function, urinary/bowel incontinence, sexual dysfunction, trouble breathing, and difficulty sitting upright (O’Sullivan and Schmitz...
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...I. Course Prerequisites: II. Course Description: NURS 101, BIO 311, CHEM 107/170 This course introduces the student to the scientific principles of foundational concepts, theory and technical skills. Concepts that frame the curricula are introduced: caring behaviors, communication, culturally congruent care, ethical frame work, legal aspects, critical thinking, leadership, research and professional nursing role. Using simulated labs, computer programs and videotapes, the student will develop and master selected psychomotor skills. III. Required Text(s) Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2012). Fundamentals of Nursing (8th ed.). St. Louis, MO: Mosby/Elsevier. ISBN: 9780323079334 Perry. A. G., & Potter, P. A. (2009). Clinical nursing skills and techniques (7th ed.). ISBN10:0323052894 Wilkinson, J.M. & Ahern, N. R. (2009). Prentice Hall nursing diagnosis handbook with NIC interventions and NOC outcomes (9th ed.). Pearson: Upper Saddle River, NJ. 1 IV. Recommended/Supplemental Text or Reference Material Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2012). Study guide: Fundamentals of Nursing (8th ed.). St. Louis, MO: Mosby/Elsevier. ISBN: 9780323084697 American Psychological Association (2010). Publication manual of the American Psychological Association ( 6th ed.), Washington, DC: Author V. Course Objectives: Upon completion of this course the students will be able to: 1. Use scientific rationale to demonstrate basic psychomotor nursing...
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...Data Analysis-Why? A. To study and examine data collected 1 Synthesis of data B. Identify community strengths C. Identify community health needs D. Determine need for further data collection: 1. find if research has been done. 2. Data gaps: determine need for further data collection. Make sure you can support data gaps with information from assessment. E. Look for trends/patterns; how often do you see a recurrent theme? F. Discovery of causative relationships: the R/T portion. I. Basic Steps of Data Analysis(4) 2 Categorize-e.g. by demographics, commonalities. E.g. intra/extra community for health and social services 3 Summarize 4 Compare 5 Inference/Interpretation II. Categorize Data 6 There are many ways to sort and categorize data e.g. demographically by age groups, by problem type 7 Geographic approaches may be used 8 Use of model; we are using the wheel from Neuman’s model. 9 Look for data convergence when categorizing-e.g. how many times do we see data converging in different categories? 10 Look for commonalties, health resources that are available. SEC, age, etc. III. Data Summary 11 Summary statements-summarize each table. 12 Summary statistics-put data into percentages and rates so that different areas/communities can be compared. Raw numbers will not work to compare different areas. 13 Graphic methods of data summary: 14 Remember that tables need concise summary data. P. 222, can put population...
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...there are less medication errors and greater positive outcomes for the patients. The Nurses holding BSN degree have shown that they have decreased the risk of patient’s death. This topic will focus on the differences between ADN and BSN nursing care, based on the example of treatment a patient receives from both types of nurses. Associate Nurse An Associate degree nurse is a nurse with 2 to 3 years nursing training. Graduate of this program is qualified to take the NCLEX to become a registered nurse. An Associate degree nurse has many roles such as teaching the patient about their conditions, assessing the patient’s condition, care plans, doctors’ orders, treatments, and medication. Some of the responsibilities that ADN nurses have are supervisory of the LVN, LPN, CNA, and other healthcare workers. ADN nurses thrive with more independence along with more complex situations with lots of ill patients. Baccalaureate Nurse A Baccalaureate Nurse is represented as a nurse with 4 to 5 years nursing training. Graduates of this programs are qualified to take the NCLEX exam to become a registered nurse. BSN nursing includes the role of assessing, communicating, teaching, leading, critical thinking, providing care, and strong communications between nurses, doctors to go along with great problem solving. BSN nursing practice including health promotion, early detection of health deviations, disease prevention, and adequate treatment of the patients and response...
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