Care plan

Topics: Nursing care plan, Health care, Nursing Pages: 6 (949 words) Published: December 19, 2013
Ivy Tech Community College of 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 relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.

HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.

IVY TECH COMMUNITY COLLEGE OF INDIANA – REGION 6
NURSING PROGRAM

NURSING HISTORY & PHYSICAL ASSESSMENT FORM

Student _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit _Oncology_BMH___ Instructor

Health History

Biographical Data:

Patient's Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________

Birthplace: Randolph County__ Ethnic origin/Race: _Caucasian_ Occupation: previous factory worker_

Work status : retired_________ Educational background __High school______________

History source initials ___Pt__ Relationship to client __self__________________

Transcultural Considerations: (Time, space, touch, & value orientation, language considerations, spiritual beliefs, education level)

Pt speaks English. High school was the highest education received. She worked at a factory for years and then quit to stay home and raise her two kids.

Special Needs:
Walker

Reasons for Seeking Care: (Brief statement in patient's words that describes reason for visit - Chief Complaint) Pt states she is here due to her ovarian cancer.

Past Health History:

Approximate hospitalization dates:
1/17/2010

Serious or Chronic Illnesses (Approximate onset):
Pt has a hx of: HTN, gallbladder disease, hiatal hernia, ulcers, diabetes type 2, hypothyroidism, depression, ovarian cancer, arthritis, migraines, cataracts and a right leg fx. Pt has also had these surgeries: hysterectomy, appendectomy, cataracts, cholecystectomy, colon resection, hernia, thyroidectomy, tonsillectomy, and adenoidectomy.

Obstetric Rotation

Current Obstetric Assessment:

Gravidity ______ Term ______ Preterm ______ Abortions ______ Living ______

Blood Type _____ Rh Factor _____

LMP _______ EDC _______ RhoGAM Status ______ DTR ________ (if applicable)

Date & Time of Delivery __________________________________

Type of Delivery ___ SVD ___ Forceps ____ Vacuum ____ Cesarean Section

___________ Anesthesia/Analgesia _______ EBL

Perineum: ______ Intact ______ Episiotomy _____ Laceration & Location__________________

Please note any current obstetrical problems/complications (GDM, pre-eclampsia, etc.)

Please note any past obstetrical problems/complications: (Condition, duration, treatment)

Infant Data:

Gender ___________Apgar Score ___ / ___ Gestational Age _____weeks Cord Vessels_____
Feeding method ______ Weight at Birth...
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