I. SAFE AND QUALITY NURSING CARE CORE COMPETENCY 1: Demonstrate knowledge based on health/illness status of individual/ groups Indicators : ○ Identifies health needs of patients/groups ○ Explains patient/group status CORE COMPETENCY 2: Provides sound decision making in care of individual/groups considering their beliefs‚ values Indicators : ○ Problem identification ○ Data gathering related to problem ○ Data analysis ○ Selection appropriate action ○ Monitor progress of action
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Psychiatric Clinical Nursing Assessment Jennifer Stokes Daytona State College Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health‚ fear of physical illness‚ hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐
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PN 0004C Weekly Clinical Planning Sheet Student Name: S.H Care plan #5 Patient Initials: t.l Age/Sex: 73/f Allergies: Potassium Nurse on Duty: Regin Admission Date: 06/29/2013 Admitting Physician: Dr. Cole Consulting physician: Code status: Hospice‚ dnr Activity Level: As tolerated Diet: nectar thick/puree Patient History and Diagnoses: primary
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References Student X Baton Rouge General School of Nursing Nursing Care Plan for Herpes Zoster Patient Patient is a 33 year old African American female with infected herpes zoster‚ sepsis‚ and gastroenteritis. The patient was admitted to the Mid-City Baton General Hospital on Sunday‚ June 15‚ 2014 for infected herpes zoster‚ where a chest x-ray‚ blood culture‚ specimen arm wound culture‚ and urinalysis was performed. The results showed lungs clear‚ heart size with in normal limits‚ and no abnormal
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THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO SCHOOL OF NURSING NURS.3208 Nursing Care of Childbearing Families: Clinical Application Written Requirements DAILY ASSIGNMENTS Each week‚ daily assignments are to be submitted according to the directions of the clinical instructor. Use Daily Assignment grid (next page). One daily assignment will include a comprehensive list of all nursing diagnoses consistent with NANDA and ranked in priority order. State a rationale from
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Indiana Nursing Program – Region 6 Nursing Care Plan and Evaluation Student: __ Instructor: _Date: _1-28-2010_____ Instructions: 1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2. All nursing care plans must be typed (Times New Roman‚ 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course. 3. The grading rubric must be attached – last page of nursing care plan. 4. All
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Care Plan Worksheet Student: Date of Care: Age/Gender: Rm Number: Code Status: full Allergy: NKA Admitting Diagnosis : embolic cerebral vascular accident (CVA)‚ right side Current Medical/Surgical Diagnosis: chronic left ventricle thrombus on anticoagulant‚ hypertension‚ chronic kidney disease stage 3 Past Medical/Surgical History: metastasis of prostate cancer‚ primary; bone cancer‚ secondary; cardiomyopathy‚ a central hypertension‚ left bundle branch lock‚ past substance abuse
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Care Plan Problem: Risk for bleeding r/t postpartum complications. Patient Centered Goal: Patient will not experience any abnormal/excessive bleeding by the end of clinical shift. Expected Outcomes: 1. Patient will experience lochia reducing in amount and lightening in color by the end of clinical shift. 2. Patient will observe fundus that is firm‚ midline‚ and decreasing in height by the end of clinical shift. 3. Patient will verbalize understanding of signs and symptoms
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CARE PLAN Bipolar Disorder‚ Manic Episode [pic] Risk for Other-Directed Violence At risk for behaviors in which an individual demonstrates that he or she can be physically‚ emotionally‚ and/or sexually harmful to others. RISK FACTORS • Restlessness • Hyperactivity • Agitation • Hostile behavior • Threatened or actual aggression toward self or others • Low self-esteem EXPECTED OUTCOMES Immediate The client will • Be safe and free from injury throughout hospitalization
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Hospital/IU | Cultural/Ethnic Background/Needs: None | Religion: | Did not state | Primary Language: | English | Educational Needs: | Cognitive Impaired | Discharge Planning/Self-Care Needs: Discharged to hospice. Self-care deficit. | Admission Date: | 3/31/13 | Time: 0500 | | Admitted From: (Home‚ ECF or ?) | Nursing Home | Admission DX: | Aspiration related pneumonia | Chief Complaint (“patient’s own words” – PUT IN QUOTES): patient unresponsive due to cognitive impairment. | Medical HX:
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