Immunization History

Immunization History

History of Present Illness (Detailed):

Past Medical/Surgical and Injury History:

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

Spiritual Well-Being:

Family History of Illness:

Immunization History:

Developmental Stage in Life:

Description of Procedures (Surgeries) Performed this Admission:

Review of Systems – brief history of each system and use abbreviated format, not complete sentences

General:

Psychiatric:

Skin, hair, and nails:

Lymph nodes:

HEENT (head, eyes, ears, nose, mouth, throat):

Neck:

Blood:

Breasts:

Cardiovascular:

Respiratory:

GI:

GU:

Musculoskeletal:

Neurologic:

Endocrine:

Section II

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan ) References done in APA Format (5 Points)

Pathophysiology of Disease Process

(Points 10)

Classic Signs and Symptoms of Disease Process

(5 Points)

Section III

Physical Assessment

(15 Points)

Physical Assessment:

Vital Signs (T, P, R, BP, SPO2)

General Appearance

Psychiatric

HEENT

Neck

Breasts and Lymph Nodes

Pulmonary

Cardiovascular

Skin and Nails

Abdomen

Genitourinary

Pelvic and Rectal

Extremities

Musculoskeletal

Neurological (DTR’s, reflex grading, cranial nerve evaluation)


Incisions

Drains

Diet/Nutrition

IVs

Intake and Output

Pain assessment (include reassessment)

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Section IV

Diagnostic Data

(5 Points)

Inlcude pertinent diagnostic tests, including labs, EKG, and X-Rays

Diagnostic Tests

Patient’s value

Normal Range

Inference(why is this patients value abnormal)

Section V

Treatments and Procedures

List all treatment and procedure interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

( 5 Points)

Treatments and Procedures

Day & Times

Rationale

Section VI

Teaching and Health Promotion

( 5 Points)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

Section VII

(5 Points)

List of Nursing Diagnoses (Minimum of 5) Use your assessment of your client’s human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.

Human Needs

Nursing Diagnoses

(Circle Selected Nursing Diagnoses)

Nursing Diagnoses Statements

Oxygenation

  1. Perfusion (Cardiac)
  2. Acid Base Balance
  3. Ventilation
  4. Diffusion

Decreased Cardiac output

Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral Impaired Gas exchange Ineffective airways cleaning Ineffective Respiratory pattern Difficulty maintaining spontaneous ventilation, Respiratory dysfunctional response to Weaning High risk of Asphyxia High risk of Aspiration

Fluid & Electrolytes Balance

  1. Acid Base Balance
  2. Metabolism
  3. Intracranial Regulation

Liquids, excess volume Liquids, Volume Deficit Liquids, high risk of volume deficit Body temperature: high risk of impaired Hypothermia Hyperthermia Ineffective Thermoregulation

Elimination

Constipation Subjective Constipation Chronic Constipation Diarrhea Fecal Incontinence Urinary, impaired elimination Urinary incontinence: stress Urinary Incontinence: reflects Urinary Incontinence: emergency Urinary Incontinence: Functional Urinary Incontinence: total Urinary, retention Self-care, deficit: use the potty / toilet

Nutrition

  1. Energy
  2. Cellular structure and function
  3. Failure to Thrive
  4. Metabolism

Nutrition, altered: excess Nutrition, altered: by default Nutrition, potential alterations: excess Self-care, deficit: feeding Swallowing, impaired Ineffective Breastfeeding interrupted breastfeeding Effective Breastfeeding Infant Feeding ineffective pattern

Sleep

Sleep pattern disturbance

Mobility

Disuse, high risk of syndrome Physical mobility, disorder Peripheral Neurovascular, high risk of dysfunction Activity intolerance Activity, high risk of intolerance

Self-care, deficit: dressing / grooming

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