Richland Community College Nursing Care Plan Paper

Nursing care plan for Case Study, Chapter 51, Assessment and Management of Patients With Diabetes

2. Jerry Thomas is a 26-year-old type 1 diabetic. He was originally diagnosed at the age of 14, and currently manages his disease with an intensive regimen of insulin injections. Jerry is employed as a schoolteacher and soccer coach. He presents today with a 2-day history of vomiting and diarrhea. He has been closely monitoring his blood glucoses and is using regular insulin for high blood glucose levels. He has only been able to tolerate liquids such as Gatorade, but today he is unable to even tolerate that, and comes to the clinic for evaluation of possible diabetic ketoacidosis (DKA). (Learning Objective 9)

Case Study, Chapter 47, Management of Patients With Gastric and Duodenal Disorders

Ms. George is a 32-year-old computer programmer. Over the last several months, she has had increased episodes of a burning sensation in the mid epigastrium and back. The pain subsides after eating. Based on her history, the physician orders an endoscopy that reveals several peptic ulcers. Treatment of the ulcers includes antibiotics, proton pump inhibitors, and bismuth salts. (Learning Objectives 1 and 3)

Case Study, Chapter 57, Management of Patients With Female Reproductive Disorders

June Brite, 35 years of age, is admitted to the medical-surgical unit after a vaginal hysterectomy

with bilateral salpingo-oophorectomy for the treatment of uterine cancer. (Learning Objective 7)

Case Study, Chapter 54, Management of Patients With Kidney Disorders

2. Dudley Wayne is a 62-year-old factory worker. Mr. Wayne makes an appointment with his primary care practitioner because he has lost 15 pounds in the last 2 months, and has recently noticed blood in his urine. He denies pain on urination. During the admission assessment, Mr. Wayne states that he is a two-pack-per-day smoker and just thought he was losing weight because of increased work stress. He also states that he worked 30 years in a building that was recently closed due to asbestosis contamination. Upon physical examination, Mr. Wayne complains of pain when the provider percusses and palpates his flank area. A CT scan is ordered along with an ultrasonogram; both reveal a mass in the renal pelvis. (Learning Objective 3)

NURSING CARE PLAN RUBRIC

Include the case study in your document.

Do not write the NCP using a grid format… use an essay format/ bullet point using the numbers of this rubric.

All NCP will be graded according to the following rubric.

1) Definition of the medical diagnosis __________10

etiology/pathophysiology

2) Common signs and symptoms ___________5

3) Potential complications ___________5

4) Head to toe physical assessment you are to write one….use the data in the case if there is none you create it as if this was your patient. NOT a to do list!

__________10

5) Diagnostic and lab studies ___________5

normal values

expected abnormalities

6) ALL NANADA Nursing diagnoses __________10

www.deanza.edu/faculty/hrycykcatherine/NANDA_2015-…

7) Develop 3 NANDA priority nursing diagnoses __________10

8) State a patient plan AND goal for each of the __________10

priority nursing diagnosis

9) Write interventions for each of __________10

priority nursing diagnosis

10) Write scientific rationales for you you ___________5

interventions

11) Write evaluation of your interventions __________10

your plan or make changes

12) List of typical medications __________10

category

usual dosage

side effects

patient teaching

HEAD TO TOE ASSESSMENT

Watch www.youtube.com/watch?v=gG8kh8MfnGY

HOW TO WRITE: YOU ARE TO CREATE A PICTURE OF YOUR PATIENT

These are topics for you to consider documenting as applies to your client.

General appearance:

• Affect/behaviour/anxiety
• Level of hygiene
• Body position
• Patient mobility
• Speech pattern and articulation

This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9.

2. Skin, hair, and nails:

• Inspect for lesions, bruising, and rashes.
• Palpate skin for temperature, moisture, and texture.
• Inspect for pressure areas.
• Inspect skin for edema.
• Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.
• Inspect nails for consistency, colour, and capillary refill.

Head and neck:

• Inspect eyes for drainage.
• Inspect eyes for pupillary reaction to light.
• Inspect mouth, tongue, and teeth for moisture, colour, dentures.
• Inspect for facial symmetry.

4. Chest:

• Inspect:
  • Expansion/retraction of chest wall/work of breathing and/or accessory muscle use
  • Jugular distension
• Auscultate:
  • For breath sounds anteriorly and posteriorly
  • Apices and bases for any adventitious sounds
  • Apical heart rate/rhythm
• Palpate:
  • For symmetrical lung expansion
• Breasts

Abdomen/GI:

• Inspect:
  • Abdomen for distension, asymmetry
• Auscultate:
  • Bowel sounds (RLQ)
• Palpate:
  • Four quadrants for pain and bladder/bowel distension (light palpation only)
• Check urine output for frequency, colour, odour.
• Determine frequency and type of bowel movements.

Genitourinary:

Check urine output for frequency, colour, odour.

Female: vaginal discharge

Male: circumcision, discharge

Musculoskeletal:

• Check if full or partial weight-bearing.
• Determine gait/balance.
• Determine need for and use of assistive devices.

Inspect:

• Arms and legs for pain, deformity, edema, pressure areas, bruises
• Compare bilaterally
• Palpate:
  • Radial pulses
  • Pedal pulses: dorsalis pedis and posterior tibial
  • CWMS and capillary refill (hands and feet)
• Assess handgrip strength and equality.
• Assess dorsiflex and plantarflex feet against resistance (note strength and equality).

Back area (turn patient to side or ask to sit up or lean forward):

• Inspect back and spine.
• Inspect coccyx/buttocks.

Tubes, drains, dressings, and IVs:

• Inspect for drainage, position, and function.
• Assess wounds for unusual drainage.

Sample format for documentation:

General Status

Vital signs

Head, Ears, Eyes, Nose, Throat

Neck

Respiratory

Cardiac

Abdomen/GI

GU

Pulses

Extremities

Skin

Neurological