Patient Teaching Paper
Major Care Plan
Student Name: Jane Doe
Date of Care: 10/15/13
Pt. Initials: RC
Rm #: 453-2
Chief Complaint: Abdominal Pain
Medical Diagnosis: Acute Appendicitis/Laparoscopic Appendectomy
BCF’s & Power Components
Universal Self-Care
Requisites
Developmental
Requisites
Health Deviations
Requisites
Self-Care Deficits
Unable or Unwilling:
BCF:
1. Age: 64 years
2. Gender: Male
3. Developmental State: a. (Erikson Theory) Integrity vs. Despair. b. Cognitive: Alert/Oriented x 4, long and short-term memory in tact. c. Physical: Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
4. Relevant Life Experience: Type-2 Diabetic; smoker in process of quitting (currently using nicotine patch); CABG 2008
5. Health Care System: Pt arrived at emergency room approximately 04:00 on 10/12/13 with sharp right side abdominal pain 9/10 on pain scale, nausea, and vomiting, Temp: 99.2F. Abdominal U/S confirmed inflamed appendix.
6. Health State: Admitted at 14:36 and appendectomy surgery performed from 19:32 to 20:50 on 10/12/13. Assessment findings: BP 136/83, HR 86, RR 14, O2 Sat 96 on oxygen 2L nasal cannula, Temp 98.4F, abd pain 3/10. Lungs: clear and equal breath sounds; apical pulse: auscultated, strong, regular; pulses: equal, regular, strong radial and pedal sites, no edema. Capillary refill immediate (less than 2 seconds). Negative Homan sign bilaterally. Pt expresses interest in leaving hospital as soon as possible. Labs: last accu-check 18:46 on 10/14/13: BG 114. Soft diet. Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
7. Socio-Cultural Orientation: Caucasian male, divorced, lives alone, has two grown daughters in their 30’s who live in California. Girlfriend is ER Registered Nurse of 20 years, at AV Hospital. He is a retired mechanic. No religious affiliation.
8. Available Resources: Blue Cross HMO insurance. Lives on sufficient retirement funds and social security.
PC:
1. Aware Of Self &
Student Name: Jane Doe
Date of Care: 10/15/13
Pt. Initials: RC
Rm #: 453-2
Chief Complaint: Abdominal Pain
Medical Diagnosis: Acute Appendicitis/Laparoscopic Appendectomy
BCF’s & Power Components
Universal Self-Care
Requisites
Developmental
Requisites
Health Deviations
Requisites
Self-Care Deficits
Unable or Unwilling:
BCF:
1. Age: 64 years
2. Gender: Male
3. Developmental State: a. (Erikson Theory) Integrity vs. Despair. b. Cognitive: Alert/Oriented x 4, long and short-term memory in tact. c. Physical: Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
4. Relevant Life Experience: Type-2 Diabetic; smoker in process of quitting (currently using nicotine patch); CABG 2008
5. Health Care System: Pt arrived at emergency room approximately 04:00 on 10/12/13 with sharp right side abdominal pain 9/10 on pain scale, nausea, and vomiting, Temp: 99.2F. Abdominal U/S confirmed inflamed appendix.
6. Health State: Admitted at 14:36 and appendectomy surgery performed from 19:32 to 20:50 on 10/12/13. Assessment findings: BP 136/83, HR 86, RR 14, O2 Sat 96 on oxygen 2L nasal cannula, Temp 98.4F, abd pain 3/10. Lungs: clear and equal breath sounds; apical pulse: auscultated, strong, regular; pulses: equal, regular, strong radial and pedal sites, no edema. Capillary refill immediate (less than 2 seconds). Negative Homan sign bilaterally. Pt expresses interest in leaving hospital as soon as possible. Labs: last accu-check 18:46 on 10/14/13: BG 114. Soft diet. Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
7. Socio-Cultural Orientation: Caucasian male, divorced, lives alone, has two grown daughters in their 30’s who live in California. Girlfriend is ER Registered Nurse of 20 years, at AV Hospital. He is a retired mechanic. No religious affiliation.
8. Available Resources: Blue Cross HMO insurance. Lives on sufficient retirement funds and social security.
PC:
1. Aware Of Self &