...A&M UNIVERSITY College of Nursing BASIC CONCEPTS PRACTICUM – NURS 3263 DATA COLLECTION TOOL Student’s Name Date April 5, 2011 Biographical data Client’s initials P.M. Unit/Room No. A735 Age 64 years old Gender F Ethnicity Black Religion Baptist Marital Status Widowed Occupation Unemployed Date of Admission March 31, 2011 Admitting Problem/Diagnosis Unstable Angina Chief Complaint (Why did the patient come to the hospital – in patient’s own words) “My chest was constantly hurting and I couldn’t figure out what was causing it and now my back is killing me.” Past Health History Asthma ________ Emphysema _______ Bronchitis ________ Pneumonia ________TB________ Angina ______ MI ______ Anemia ______ Hypertension _______ Rheumatic Fever _______ Pacemaker _______ Peripheral Vascular Disease _________ Blood Disorders _________ Stroke _________ Skin Disease ______ Bladder Infections _Kidney Disease ___________ Ulcers ________ DM _________ Dental Problems _________ Fractures _________Congenital Heart Defects Surgeries Family Health History Condition Family Members Condition Family Members Heart Disease Mom died of heart attack Tuberculosis Hypertension Asthma Stroke Mental Illness Diabetes Alcoholism Cancer Aunt died of mylethoma Kidney Disease Other Health Problems in Family:...
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...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 Program CLIENT INFORMATION FORM Student's Name Date of Care: Client Initials Room Number Sex: Age : Admission Date: Admitting Diagnosis: Rt. Lobe infiltrate, Breast & Bone Cancer Secondary Diagnosis if any): Respiratory Distress Surgery Type/Date (if any): Lumpectomy on Rt. Foot at 2002 Working Medical Diagnosis/Etiology (describe definition, pathophysiology, and sign/symptoms) Metastatic Breast Cancer Metastatic breast cancer is the term used to describe cancer that has spread from the original site in the breast to other organs or tissues in the body. Cancer cells can break away from the original cancer in the breast and the cancer cells that break away can spread to other parts of the body via blood vessels or lymphatic vessels. The original site where the cancer cells came from is called the primary cancer. When cancer cell travels from the breast around the body they can lodge themselves in various body organs or tissues. These cells can begin to form breast cancer in new place and this new cancer is called secondary or a metastasis. Breast cancer most commonly spreads to one or more sites: bone, liver, brain and lungs. The sign or symptoms that may experience will depend on where the cancer is in the body and the extent of the cancer. If its spread to the: Bone- pain is fairly constant, aching pain. It may...
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...om pain NUR 106 Clinical Worksheet Student Name: Clinical Week of Care: 2/9-2/13/15 Facility: Cottonwood Room #: A08 Pt. Initials: Pt. Age: 68 Pt. Gender :M Allergies: Adhesive, Amitriptyline, Hydromorphone, Zolpidem-tartrate, Clindamycin Ethnicity: Cauc. Religion: Protestant Social Support: Wife in Dgo, Education: Police academy Occupation: Retired police Admit Date: 01/26/15 Present Diagnosis: Rehabilitation procedure NEC, Orthopedic aftercare NEC, Depressive disorder, Chronic pain NEC, Hypertension NEC, Insomnia NOS, Alcohol cirrhosis liver. Stump is still draining, swollen (2/19) Code Status: I (full) Reason for admission to Facility: Rehab for AKA (Above the Knee Amputation) Past Medical History (from chart):Chronic pain, traumatic blindness right eye, COPD, Asthma, restless leg syndrome, obstructive sleep apnea, AFIB, sick sinus syndrome, HTN, venous insufficiency, cirrhosis(liver),esophageal varices with bleed. Admitting/ Attending Physician: Dr Andreas/ Burnside Diet ordered:Regular Activity Ordered: Up as tolerated/PT Transfer Assistance: 1-person Toileting:Assist Isolation: No Oxygen: 3 L/min Finger Sticks: NA Vital Signs from Previous Shift: T:98.2f P:84 R:18 BP:129/83 Height: 6’1” Weight:232lbs. BMI:30.6 IV Site: none IV Fluids: none Last 24 hrs intake: na Output: na Patient Introduction (2-3 sentences):RM is a a 68 year old male. A former Los Angeles police...
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...This was a priority of mine after missing points on my past careplan for not assessing these things. It was difficult to meet this goal with my patient, as she has difficulty speaking aside from confirming “yes” and “no”. However, with other residents, I was able to gather more information to assess these subjects. I feel as though I am improving in my skills in gathering this type of information. What new knowledge related to nursing did you learn today? I was able to learn new nursing knowledge by having the chance to administer medications through a PEG tube. I was able to check placement of the tube my injecting air into the tube and listening with my stethoscope. I enjoyed this experience and getting to practice skills and techniques that we have discussed in lecture in the past. I also learned many...
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...1. Studying, Money, Jobs, Homesickness, Depression, Sickness/Health Conditions, Friends/Roommates, Partying, Relationships & Choosing majors are considered to be the top ten common problems students face during college. (Garfieldgatehubpages.com, 2012) A. What are some of the experiences you face? Have you ever found a solution to your problem? How do you overcome these things? B. You meet up with your friends or your partner and you go out and party, drink, do drugs but have you ever consider the consequences you will face later an in life? C. Then, today we are going to talk about Friends/ relationships, partying , health & sickness and some ideas you might gain from this information might be useful in the future for you or a friend that’s in College. (Transition: What I’m going to talk to you about now is about our Friends and Relationships) 2. Did you know friends and personal relationships affect you decisions. A. All our decisions in school are being affected by our relationships, that includes friends, family, boyfriend’s, girlfriend's, all of the people we decide to surround our self's with (yourlife.usatoday.com, 2011). B. According to USATODAY.com "The relationship game among college-age adults today is a muddle of seemingly contradictory trends. Recent studies indicate that traditional dating on campuses has taken a back seat to no-strings relationships in which bonds between young men and women are increasingly brief and sexual”...
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...nursing interventions to help him manage his weight in addition; Ahmed has always been a practising Muslim with a strict religious diet but due to deterioration in his mental state, he had abounded his Halal diet and started even consuming pork products: hence my intervention. It is important to help Muslim patients maintain a Halal diet; according to (Holland and Hogg 2010) if Halal meat cannot be provided in hospital, vegetarian meal should be provided. Bear in mind those observations, I approached Ahmed to explore the reasons why he had decided to eat pork products and he was adamant that regardless of him being Muslim, it was his choice to determine what he eats and that I had no business restricting his diet. Consequently, I drew a careplan that specifically made mention of his...
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...Effective Communication Paper “Within boundaryless organizations context, teamwork, and communication replace formal lines of authority” (Lombardi & Schermerhorn, 2007, p. 64). Effective communication is the most important aspects of any organization. Without effective communication an organization can be unsuccessful and fail. Some communication obstacles a caregiver could face on a daily basis are: working with Alzheimer’s patients and memory loss, make sure to speak clearly, slowly, and use the correct tone and volume, make sure you have the patients full attention, use effective nonverbal signals, use appropriate behavior and show the patient that you care and are listening, and communicate effectively with other in the organization and other sources that may have to be dealt with. (RNCentral, 2012). EFFECTIVE TEAMWORK One way to share information and ideas is by working in teams. “A team is a small group of people with complementary skills, who work together to achieve a shared purpose and who hold themselves mutually accountable for its accomplishment” (Lombardi & Schermerhorn, 2007, p. 76). “Teamwork is essential in the provision of healthcare. The division of labor among medical, nursing and allied health practitioners means that no single professional can deliver a complete episode of healthcare” (Leggat, 2007, p. 1). Through teamwork, people work together to accomplish the goals set forth by members of the team or organization. Teamwork requires leadership...
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...Pulmonary embolism is a serious and potentially life threatening condition. When the blood supply to the lungs gets clogged with a clot pulmonary embolism can happen. It can happen even in healthy people. Sudden blockage of blood vessel artery in the lungs can cause pulmonary embolism. Usually it is a blood clot. Most cases the clots can be small but it can still damage the lungs. If the clots are big enough it can be deadly. Quick treatments will reduce the risk for future problems (Lung disease, 2011). Most common of the symptoms are sudden shortness of breath which are a sharp chest pain that is worse when you cough or take a deep breath, a cough that brings up pink and foamy mucus (Lung disease, 2011). Anxiousness, sweating, light headed, tachycardia or palpitations are some other general symptoms that can occur (Lung disease, 2011). Most cases pulmonary embolism is caused by a clot that breaks loose and travels to the lungs. Having clots in deep veins like in deep vein thrombosis can cause pulmonary embolism (Lung disease, 2011). More than 300,000 people are affected by pulmonary embolism each year (Lung disease, 2011). Any diseases that can form a clot in the body can lead to pulmonary embolism. Some of the factors that can increase the risk for pulmonary embolism includes, being inactive for long periods of time. This mainly happens after surgery or major illness, sitting in long flights or cars (Lung disease, 2011). As mentioned in the article of lung diseases about...
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...Running Head: TEACHING PLAN Teaching Plan about Cesarean Incision Care for R.R. Teaching Topic Patient R.R. is a 27 year old female who is in need of teaching. R.R. delivered a healthy baby girl via cesarean section on September 18, 2009. R.R. had to have a cesarean section due to labor complications and meconium present in the amniotic fluid. The topic that must be taught to R.R. is proper incision care and to identify the signs and symptoms of infection for her cesarean incision. The patient is to be discharged today, and has had her staples removed. Educational Assessment R.R. is a 27 year old female who has a high school education and 2 years of community college education. No learning barriers were identified. R.R. stated that she prefers brief and to the point instructions with common terminology used instead of medical terminology. Spanish is R.R. first language, but she understands English well. The patient stated that she learns best by demonstration and written information. R.R. is currently a home-maker. She is married and this is her and her husbands’ first child. R.R. is very eager to learn and extremely cooperative. No learning barriers were observed. Psychologically R.R. seemed a bit restless and eager to go home and join her husband, but her attitude remained positive and cooperative. Based on the learning assessment of R.R., it is best for her to observe the proper care of her incision, and to have written information to refer back to and also...
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...The Influence of Heritage on Current Culture Evaluation of how family subscribes to these traditions and practices is offered in detail, while offering insight and/or reflection.It is essential for nurses to provide culturally sensitive care to each and every patient in order to establish repor and maintain a safe working relationship with each individual. To provide culturally sensitive care to a nurses patient’s he or she must first assess their own beliefs, values, and culture at large. The nurse can do this by using the Heritage Assessment Tool. This tool shows the nurse how important their heritage is to them and if they have adopted their ways of life from their family’s history and influence. This gives the nurse a starting point for his or her own competency because once the nurse knows their own beliefs they will know what to keep in mind as their own biases that may hinder or limit care of their patients. The Heritage Assessment tool can then be used with the nurses’ patients in assessing how much they follow their cultural heritage. When interviewing families from different cultures one can see the disparities between them and their perception of their health maintenance, health protection, and health restoration. Applying the Heritage Assessment in Evaluating the Needs of the Whole Person The Heritage Assessment is a useful tool in evaluating the needs of the patient and in being able to provide holistic patient care. The Heritage Assessment Tool assesses whether...
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...A Critique of the Literature Effects of Nursing Rounds: on patients’ Call Light Use, Satisfaction and Safety. Introduction: The findings of this article will critically review the methods of research, population, systems and data used to obtain results regarding this study. This evaluation of the outcome would determine whether or not there was a need to change the nursing management of patient care. The study would determine if patients were happy with their care and if the rate of falls were minimised. In the health care setting, the call light is an important communication tool for the nursing staff and patients especially in an emergency situation. Title: The title clearly summarises the content of this Journal article which suggests there was either a qualitative or quantitative designed research data used to conclude the findings. There was limited context which was not clearly defined (Meade et al.2006, p 58). Abstract: This is succinct, meaning the writer has been brief and precise with the back ground information about the research article. This...
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...Attach rubric to cover of careplan submitted RUBRIC For Grading Patient Assessment and Care Plan | GRADE:(total < 40; must redo) Success/Unsuccess | | Maternal Child Nursing Course - Care Plan | | | Student: Tiffany Rogers | Clinical Date: 11/07/2015 | Site: St. Vincent’s South | | | | | | Sections | Grading Criteria | Possible Points | Points Earned | Comments | Patient Information | General Information | 10 | | | | OB/Medical/Surgical Hx | | | | | Psychosocial Hx | | | | | Lab Information/Vital Signs | | | | | | | | | Postpartum/L&D | L&D Complications (or) | 10 | | | | PP Complications | | | | | Interventions | | | | Nursing Diagnosis (3) | Problems (Exclude Pain) | 10 | | | | Goals (2 goals (short/long term) per dx | 5 | | | | Interventions (5 min per goal) | | | | | | | | | | APA 6th edition reference page | 5 | | | Medication - Classifications | Name of Drug: | 10 | | | | Dose, Range, Route | | | | | Side Effects, Time Schedule | | | | | Action | | | | | Rationale for Drug Therapy | | | | L&D or Postpartum Clinical Rotation Worksheet Chamberlain College of Nursing Student: Tiffany Rogers Date: 11/07/2015 Faculty: Ellis Vaginal Delivery Client’s Initials: JL Age: 24 G: 1 T: 1 P: 0 A: 0 L: 1 Admission...
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...policies. Within my workplace we have different policies that safeguard vulnerable adults, here are some of working practices that I believe help safeguard: • Complaints Policy Effective communication • Record-keeping Policy Risks Assessments • Confidentiality Policy Recruitment procedures • Data Protection Policy Induction • Protection of Vulnerable Adults Policy Training • Whistleblowing Policy Codes of conduct • Care plans – Person Centred Care Reflective practice • Anti – discriminatory / Anti – oppressive practice • Organisations safeguarding policy & procedures Each resident is assessed before arriving at the home, once assessed our nurse manager produces a careplan for that resident. The resident and their family have the right to be involved in developing a meaningful and effective care plan. The nursing home must work with the resident to develop an individualized, written care plan and must update it at least quarterly and any time your condition changes. Each resident important right is to receive good care. To give good care, the nursing home staff must plan to support the needs, abilities, interests and preferences. Under the law, residents and families are partners in this planning process. They have the right to give information, ask questions, participate in care plan meetings, offer suggestions, review care plan documents and accept or refuse offered care. If they get...
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...ACUTE CARE ASSIGNMENT Introduction For this assignment I have chosen to use a patient on a Medical Rehab Ward that became acutely unwell very suddenly and was eventually diagnosed with Urinary Sepsis before being transferred to an Acute Medical Ward for further treatment. The purpose of this assignment is to show how I as the nurse, managed the situation in the assessing of the patient from the onset of their symptoms using the Airway, Breathing, Circulation, Disability framework. The planning and implementing of the care required and evalutaing constantly to ensure that the care provided is working and how I communicated with the relevent medical staff using the ISBAR tool of communication. The timeframe is over a 36 hour period from onset of symptoms to transfer. I will begin by giving a definition of Sepsis, discuss the ABCDE method of assessment and a brief background as to why the patient is in hospital as well as a brief past medical history. Sepsis, a potentially life-threatening complication of a localised infection, can rapidly lead to acute deterioration risking multi-organ failure and death. (Dellinger et al 2008) Sepsis is quite common and it is therefor imperative that every nurse on every ward be aware of the signs and symptoms of Sepsis and the appropriate measures to take to manage it should their patient become Spetic. Having an effective and proven assessment tool such as the ABCDE approach can help assess, treat and therefore improve the outcome for...
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