NURS 489 Nursing Care Plan

NURS 489 Nursing Care Plan

NURS 489 Nursing Care Plan

Client Code Name: D L

Client’s Age: os Gender: F

Present Medical Diagnoses: AFIB, HTN, hypothyroidism, chest Pressure

Present Surgery (if applicable): NO

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

Spiritual Well-Being:

Allergies: Alleres tetracy _____ Augmentin Code Status:

Vital Signs: T & 8 P 89. R 15 BP 120/80

SPO₂ A

__________________________________________________________________________________________________________

Fall Risk Assessment (include score): Pain assessment (include reassessment):

Time : 8am

Score :

Intervention :

Reassessment Time : 11am

Score : 0

Diagnostic Assessments-Important EKGs, X-Rays, and Labs

Lab/Other Test : WBC, RBC, HG?, HCF, PLATELET, MONOCYTE

Patient values : 5-2, 2-52, 39-6, 87-2, 186, 7-2

Inference

Medications Ordered for Client:

Medication and Dose with : Aspirin, Famotidin, nebivolol, enoxaparin

Generic Name of Drug : 81m, 40mg, 10mg, 100mg

Brand name : 9

Times of Administration

Indications of Drug

Adverse Effects

Nursing Implications

Treatments and Procedures : Pti Enoxaparin

Day & Times : 1 a day

Rationale : to treat blood clots

Nursing Interventions:

Assessment Findings : R

Diagnoses

Expected Outcomes

Nursing Interventions

Evaluation

Reflections of the day:

NURS 489 – Synthesis of Complex Nursing Care

Edyth T. James Department of Nursing

Daily Clinical Log

Client Name: _____________________________

Client’s Age: _________ Gender: ________________

Present Medical Diagnoses: ____________________________________________________________________________

Present Surgery (if applicable): _____________________

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

__________________________________________________________________________________________________________________________________________________________________

Spiritual Well-Being: _________________________________________________________________________________

Allergies: __________________________ Code Status: _________________________

Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________

Physical Examination:

General Appearance:

Psychiatric:

HEENT:

Neck and Lymph Nodes:

Pulmonary:

Cardiovascular:

Skin and Nails:

Abdomen:

Genitourinary:

Pelvic and Rectal:

Extremities:

Musculoskeletal:

Neurological (DTR’s, reflex grading, cranial nerve evaluation):

Incisions:

Drains:

Diet/Nutrition:

IVs:

Intake and Output:

Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):

Pain assessment (include reassessment):

Diagnostic Assessments – Important EKGs, X-Rays, and Labs:

Medications Ordered for Client:

Treatment:

Nursing Interventions:

Reflections of the day: Edyth T. James Department of Nursing

NURS 489 – Synthesis of Complex Nursing Care

Clinical Care Plan

Student: _________________________________ Date: ______________________________

Instructor: ______________________________ Clinical Course: ______________________

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

Date of Admission: ________________ Date of Care: _____________________________

Present Medical Diagnoses: ____________________________________________________

Present Surgery (if applicable): _____________________ Date of Surgery: ______________

Allergies: __________________________ Height: ________ Weight: _________

Code Status: ________________________

Section I

General Data

(Points 5)

Chief Complaint:

History of Present Illness (Detailed):

Past Medical/Surgical History:

Social History:

Family History of Illness:

Immunization History:

Description of Procedures (Surgeries) Performed this Admission:

Section II

Pathophysiology

(Points 10)

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan)

Definition:

Etiology:

Pathophysiology:

Signs & Symptoms:

Diagnostic test:

Treatment:

Section III

Assessment

(Points 20)

Physical Assessment:

General Appearance

Neurosensory

Psychosocial

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Incisions

Drains

Diet/Nutrition

IVs

Vital Signs

Intake and Output

Pain assessment (include reassessment)

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Section IV

Diagnostic Data

(Points 10)

Section V Treatment and procedures

List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

(Points 10)

Section VI

Teaching and Health Promotion(Points 5)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

1)

2)

3)

4)

5)

Section VII (Points 5)

List of Nursing Diagnoses Use your assessment, the client’s medications, and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)

1)

2)

3)

4)

Section VIII (Points 10)

Medications

Section IX

Nursing Interventions

(Points 15)

CAREPLAN FOR “3 ” (MINIMUM) NURSING DIAGNOSES

School of Health Professions, Science and Wellness

Edyth T. James Department of Nursing

CLINICAL CARE PLAN GRADING CRITERIA

Course Number: ______________________________________

Name of Student: _____________________________________

Date:________________________________________________

Name of Clinical Professor: ____________________________________________

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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