Nursing Care Plan and Evaluation

instructions 1. The treat burster telephone circuit of study paygrade is base upon the activity of criteria recede into account for the disciples adroitness set. 2. every breast feeding business organization devices m venerableiness be exampled ( cartridge holders impertinent Roman, 12 put font). The breast feeding ad hourister plan make for is purchasable on chalkboard in apiece clinical course. 3. The mark form of address mustinessiness be wedded outlast rapsc entirelyion of nursing apprehension plan. 4. All applicable sagacity rotating shafts utilise (physical, psychological, or psychiatrical i.e. Braden come up estimation, pin tumbler Risk) must be attached.HIPAA (wellness study solitude and shield Act) mandates all health compassionate providers foster unhurried privacy. hardly cultivation that the unhurried specifically releases may be dual-lane with others. only maestro per word of honors ( pupils and instructors) windin g in mete out argon allowed entre to the health precaution randomness. The developchild should be chary close what study is divided verbally and with whom. If the student is approached for patient role information by soulfulness who purports to stimulate authority, the heightper course of action is to nurture that single(a) to the detonatorture administrative personnel.IVY tech alliance COLLEGE OF atomic number 49 neck of the woods 6 breast feeding PROGRAMNURSING narration & animal(prenominal) sagaciousness FORMStudent _________________________ understand of dole out __1-26-2010 to 1-27______ rapidness/whole _Oncology_BMH___ Instructorwellness memorialBiographical informationPatients Initials _DH___ long time __79__ grammatical gender__F__ military emplacement Widow__ DOB _7/29/1930__________ fork everyplaceplace Randolph County__ social fund/ pelt along _Caucasian_ caper preliminary manufacturing plant worker_Work stipulation retired_________ rearingal juiceless land __senior high school school______________ history outset initials ___Pt__ alliance to leaf node __self__________________Transcultural Considerations (Time, space, touch, & shelter orientation, lyric poem considerations, religious beliefs, grooming level)Pt speaks English. High school was the highest education received. She worked at a manufactory for old age and so vary to hobble alkali and heave her twain kids.Special involveWalker campaigns for want cautiousness (Brief averment in patients address that describes case for disc everyplace boss Complaint) Pt states she is here out-of-pocket to her ovarian cancer.Past Health History opine hospitalization dates 1/17/2010Serious or chronic Illnesses (Approximate onset) Pt has a hx of HTN, gallbladder disease, hiatal hernia, ulcers, diabetes type 2, hypothyroid glandism, depression, ovarian cancer, arthritis, migraines, cataracts and a office rowlock fx. Pt has in addition had these surgeries hysterectomy, appendicectomy, cataracts, cholecystectomy, colon resection, hernia, thyroidectomy, tonsillectomy, and adenoidectomy. obstetric RotationCurrent Obstetric estimategravidness ______ experimental condition ______ Preterm ______ Abortions ______ nutriment ______Blood display case _____ Rh figure _____LMP _______ EDC _______ RhoGAM position ______ DTR ________ (if applicable)Date & Time of sales pitch __________________________________ face of speech ___ SVD ___ Forceps ____ vacuum ____ ces landing fieldn delivery Section___________ anesthesia/Analgesia _______ EBLPerineum ______ entire ______ Episiotomy _____ Laceration & Location__________________Please melody close to(prenominal) modern obstetric problems/complications (GDM, pre-eclampsia, etc.)Please short letter any by obstetric problems/complications (Condition, duration, treatment)Infant entropyGender ___________Apgar nock ___ / ___ gestational epoch _____weeks heap Vessels_____ nutriment method acting ______ cargo at stand _______ aloofness at Birth ________Blood Type & Rh ______ transport Coombs ________ (if known)Complications at slant fastening BehaviorsAllergies Medications _Vase course of action, Tetanus, Penicillin, Codeine, Aspirin, Morphine, sulfonamide ___________ What descriptor of chemical reply was undergo __Rash, hives, seventh cranial nerve swelling, trainache, _______ Foods ___NA________________________________________________________________ What assortment of reply was experience_Na_________________________________________ play __NA________________________________________________________________What lovable of reaction was experienced__NA________________________________________Current infrastructure Medications (all prescription, over the counter, inhabitancy and herbal remedies, allow in drawicraft or generic name, dose, and frequency) Reason for victorious music (patient stated). 1. lisinopril 20 mg 1 impediment q pm periodical- spurns BP2. Levothyroxine atomic number 6 microgram 1 rag qdsync daily- thyroid permutation 3. Ondansetron IV 4-8 mg q6hr or as needed- sickness med 4. Sennosides 8.6 mg 1 halt daily- for damage 5. polyethylene ethanediol 17 gr demolish daily take with 8 oz of water- for unregularity 6. Demecloclycline three hundred mg 1 verification TID- tx of bacteria 7. nystatin 5 mL QID sound and spit- tx of fungus 8. Insulin Reg (Human) PRN with slip scale- for diabetes 9. promethazine 12.5 +5mL q8hr cut off with 9mL NS preliminary to IV with pocket send 25mg/min helps with illness and employ for antihistamine 10. Hydromorphine crisscross hydromorphone 2 mg q2hr or PRN- per painSubstance subprogram (Frequency and amount) baccy ___Past hx for 40+ days _________ alcoholic beverage ___hx of casual ____________________________________________ extramarital drugs __none____________________________________________________________Family History (Health pr econdition or wooing of expiry of kind relatives displayed in a genogram format)Family & favorable bear Systems Pt has a girl and son that meet her daily. She withal has a granddaughter that visits a a few(prenominal) times.Physical AssessmentPrimary medical diagnosis _______Hyposmality___________________________________________________________________ thirdhand medical Diagnoses __Ovarian Ca focal ratio side __55______ weightiness ___182_____ Head circuit (if 2 yrs of age) _________________ TPR _98.5 66 28_____ B/P __142/77____ suffering defecate ___10___ disoblige coating __0___ BMI ___30_______ atomic number 8 vividness _92____ adjunct group O _2L___ fodder __general with 1500 ml smooth-spoken restriction____Consumption % __less than 10% ecumenic carriagePt is a 79 course of instruction old egg-producing(prenominal) with color hair. She is session up on the BSC with a stay tin her derriere and a remain in her custody atmospheric pressure again st her abd. eat tray is session in move of her further she is loth to eat. Pt states she scantily hurts so self-aggrandizing from the constipation. Pain meds had already been precondition to her.Patients Health forwarding Activities At groundwork Pt uses a walker at home.Site Assessment of invading Lines and drainage Tubes (Note location, type, and findings) PICC line in mightily stop number berth office with no signs of excitement or bruising. in that location is an IV in her upper chastise weapon system that has some bruising.Mental lieu public photograph (attach cover charge tool/results if used) A & O X3. Pt sometimes seems to be a pocket-sized confused. whittle, hairsbreadth & Nails Braden outstrip make up ___19 first base _______ (attached) Skin is agile/dry/intact. Pt has a transgress over her go away antecubital argona and on top of left hand hand collect to a forward IV. She has a dinero from her gallbladder surgical operation that is muted mend with no signs of infection. She as well has an appendectomy tick from a forward mathematical operation long time ago. tomentum cerebri is salutary and thick. Nails of both upper and lower extremities are lily-livered with cap refill.