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 HISTORY & PHYSICAL ASSESSMENT FORM
Student _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit _Oncology_BMH___ Instructor
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.
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:
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.
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)
Gender ___________Apgar Score ___ / ___ Gestational Age _____weeks Cord Vessels_____
Feeding method ______ Weight at Birth _______ Length at Birth ________
Blood Type & Rh ______ Direct Coombs ________ (if known)
Complications at Delivery:
Medications: _Vaseline, Tetanus, Penicillin, Codeine, Aspirin, Morphine, Sulfa ___________
What kind of reaction was experienced: __Rash, hives, facial swelling, Headache, _______
What kind of reaction was experienced:_Na_________________________________________
What kind of reaction was experienced:__NA________________________________________
Current Home Medications: (all prescription, over the counter, home and herbal remedies, include trade or generic name, dose, and frequency) Reason for taking medication (patient stated). 1. Lisinopril 20 mg 1 tab q pm daily- lowers BP
2. Levothyroxine 100 mcg 1 tab qdsync daily- thyroid replacement 3. Ondansetron IV 4-8 mg q6hr or PRN- nausea med
4. Sennosides 8.6 mg 1 tab daily- for constipation
5. Polyethylene glycol 17 gr powder daily take with 8 oz of water- for constipation 6. Demecloclycline 300 mg 1 tab TID- tx of bacteria
7. Nystatin 5 mL QID swish and spit- tx of fungus
8. Insulin Reg (Human) PRN with sliding scale- for diabetes
9. Promethazine 12.5 +5mL q8hr dilute with 9mL NS prior to IV with max rate 25mg/min – helps with nausea and used for antihistamine 10. Hydromorphine brand: Dilaudid 2 mg q2hr or PRN- per pain
Substance use: (Frequency and amount)
Tobacco ___Past hx for 40+ years _________
Alcohol ___hx of occasional ____________________________________________
Illicit drugs __none____________________________________________________________
Family History: (Health status or cause of death of blood relatives displayed in a genogram format)
Family & Social Support Systems:
Pt has a daughter and son that visit her daily. She also has a granddaughter that visits a few times.
Primary Medical Diagnosis:
_______Hyposmality___________________________________________________________________ Secondary Medical Diagnoses: __Ovarian Ca
Height __5’5”______ Weight ___182_____ Head Circumference (if < 2 yrs of age) _________________ TPR _98.5 – 66 – 28_____ B/P __142/77____ Pain Score ___10___Pain Goal __0___ BMI ___30_______ Oxygen Saturation _92____ Supplemental Oxygen _2L___ Diet: __general with 1500 ml fluid restriction____Consumption % __less than 10% General Appearance:
Pt is a 79 year old female with gray hair. She is sitting up on the BSC with a pillow behind her back and a pillow in her hands pressing against her abd. Breakfast tray is sitting in front of her but she is unwilling to eat. Pt states she “just hurts so bad from the constipation.” Pain meds had already been given to her.
Patient’s Health Promotion Activities At Home:
Pt uses a walker at home.
Site Assessment of Invasive Lines and Drainage Tubes: (Note location, type, and findings)
PICC line in right upper chest with no signs of redness or bruising. There is an IV in her upper right arm that has some bruising.
Mental Status – General Impression: (attach screening tool/results if used) A & O X3. Pt sometimes seems to be a little confused.
Skin, Hair & Nails: Braden Scale Score: ___19 LOW _______ (attached) Skin is warm/dry/intact. Pt has a bruise over her left antecubital area and on top of left hand due to a previous IV. She has a scar from her gallbladder surgery that is still healing with no signs of infection. She also has an appendectomy scar from a previous surgery years ago. Hair is full and thick. Nails of both upper and lower extremities are yellow with cap refill.
Why Work with Us
Top Quality and Well-Researched Papers
We always make sure that writers follow all your instructions precisely. You can choose your academic level: high school, college/university or professional, and we will assign a writer who has a respective degree.
Professional and Experienced Academic Writers
We have a team of professional writers with experience in academic and business writing. Many are native speakers and able to perform any task for which you need help.
Free Unlimited Revisions
If you think we missed something, send your order for a free revision. You have 10 days to submit the order for review after you have received the final document. You can do this yourself after logging into your personal account or by contacting our support.
Prompt Delivery and 100% Money-Back-Guarantee
All papers are always delivered on time. In case we need more time to master your paper, we may contact you regarding the deadline extension. In case you cannot provide us with more time, a 100% refund is guaranteed.
Original & Confidential
We use several writing tools checks to ensure that all documents you receive are free from plagiarism. Our editors carefully review all quotations in the text. We also promise maximum confidentiality in all of our services.
24/7 Customer Support
Our support agents are available 24 hours a day 7 days a week and committed to providing you with the best customer experience. Get in touch whenever you need any assistance.
Try it now!
How it works?
Follow these simple steps to get your paper done
Place your order
Fill in the order form and provide all details of your assignment.
Proceed with the payment
Choose the payment system that suits you most.
Receive the final file
Once your paper is ready, we will email it to you.
No need to work on your paper at night. Sleep tight, we will cover your back. We offer all kinds of writing services.
No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.
Admission Essays & Business Writing Help
An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.
Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.
If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.