nursing proper care plans case Essay



Student's Brand: Antonina Polukhina

Date: 4/1/2015

Clinical Service: NCMC

PHYSICAL ASSESSMENT: Individual Initials: S i9000. E. Age group: 58 sumado a. o. Sex: Female Admitting Diagnosis: weakness/dizziness

Vital Indications: Temp. 97. 4, Heart beat 106, Respirations 18, BP 118/56 Ht/Wt/BMI: Height sama dengan 167. 64 cm, Pounds = 84. 878 kilogram, BMI 40. 2

Skin/Wounds: (Skin turgor; presence of any epidermis breakdown; sillon; wounds. ) Subjective: individual denies any skin breakdowns.

Objective: leg skin is shiny and has several enlarged veins, otherwise, epidermis is pale and consistently pigmented, no lesions or excoriations, very good turgor. Fingernails or toenails are lumination pink, stick to nail bed with 160-degree angle. Hair is usually grey, shiny and full; amount and distribution appropriate for age and gender, simply no flaking. Saline lock, proper antecubital, obvious, intact, small bruising, although no sighs of infiltration or inflammation. Eye, Headsets, Nose, & Throat: (PERRLA; general hearing; nasal congestion/drainage; mucus membrane layer color/moist; problems of difficulty swallowing. ) Subjective: individual has spectacles, denies hearing problems, nasal traffic jam. Patient says she cannot swallow her food except if it's cut and grinded, no tonsillectomy.

Target: PERLA, reading intact, nasal patency X2, mucous membranes are wet and green. Gag response intact. Thyroid gland is not really enlarged. Soreness Status: (Level of soreness; location, intensity, characteristics, activities which cause/worsen pain; activities which reduce pain) Very subjective: patient gripes of belly pain, nausea, and heart problems. C: lifeless

To: this morning

M: chest, back, stomach

D: sporadic

S: almost eight

P: strolling makes it worse, but it's tolerable when she is during sex A: nausea, dizziness

Target: patient is uncomfortable when getting up from your bed, grimacing, patient is usually nervous.


Heart: (Rate & rhythm; presence of conditional sounds (murmurs); peripheral signal – power and equality) Subjective: individual states the lady had MI, valve replacement unit surgery, takes Coumadin (bruising), chest pain, hypertonie, patient claims she has good blood clots.

Aim: prosthetic mitral valve, heartbeat are bilaterally equal but weak 2+, prolonged capillary refill, telemetry SR, last BP 118/56, INR five. 0(H), PT 54. several (H), Hgb 10. zero (L), xray mild cardiomegaly, Respiratory: (Rate; presence of adventitious sounds – examine front/back/sides (wheezes, crackles, etc); use of accessory muscles; grievances of SOB; use of oxygen) Subjective: sufferer states she has chronic bronchitis, denies SOB right now, individual states your woman had pneumococcal and influenza shot.

Objective: frequently coughing, COPD (bronchitis), ches x-ray is clear, pulse oximetry 92, fresh air source space air. GI: (presence of bowels noises – all four quadrants; issues of diarrhea/constipation; last bowel movement; occurrence of belly distension/tenderness; health assessment) Subjective: patient acquired weight loss surgical treatment, patient says that last bowel activity was the other day, denies diarrhea/constipation.

Target: CT abdomen/pelvis lap band surgery, cholecystectomy, abdomen is definitely soft, nontender, bowel sound are lively and within all 4 quadrants. Endocrine: (History/treatment/symptoms of Diabetes; thyroid, parathyroid or adrenal disorders) Subjective: patient denies diabetes and other endocrine disorders.

Aim: Glucose 121, thyroid is definitely not increased.

Nerve: (Oriented X3; DTR's; Glascow's coma scale) Subjective: sufferer states " Name is S. Elizabeth., date of birth XX/XX/XXXX, I'm at the hospital. ”

Objective: individual alert and oriented X3, Glasow's sama dengan 15, correct foot neural damage, feeling in right foot about 10 %. Muscular/Skeletal: (Extremity strength – good and similar; ambulation – independent/ with assistance/non-ambulatory; ROM) Subjective: patient states that she's employing walker. Patient verbalizes that it can be difficult to handle activity restriction, patient states she...

References: Gulanick, Meters., Myers, M. L. (2013). Nursing attention plans. Analyze, interventions, results. USA: Mosby.


 Essay upon Hcs440 Health Care Spending
Essay upon Hcs440 Health Care Spending

Health Care Spending Terri Adams-Smith HCS/440 March 8, 2012 John Branner In 2002, the United States put in $5, 267 per household on healthcare.…...

 Essay upon Ibsen’s« a Doll’s House» and Male or female Roles
Essay upon Ibsen’s« a Doll’s House» and Male or female Roles

Kelly Thompson Male or female Studies Dr . Smith 6-18-09 Ibsen's" A Doll's House" and Sexuality Roles Advantages It has been experienced…...

 Essay about ASU BIOGRAPHY 100 Examination 4 Practice Questions
Essay about ASU BIOGRAPHY 100 Examination 4 Practice Questions

п»їASU BIO 100 Exam 4 Practice Concerns 1 . Because of evolutionary ancestry, many kinds share characteristics with other kinds to which they are related. Without a doubt, according…...

 Men and Women Speak Different Dialects Essay
Men and Women Speak Different Dialects Essay

п»їKaye Trishia Canoy, Priscila Mondejar 407 Males and females Speak Distinct Languages In respect to Robert Powell, " The consistent makes for brotherhood, since when understanding implemented…...