HBU Nursing Student Care Plan

HBU Nursing Student Care Plan HBU Nursing Student Care Plan Just like the previous assignments. Two case studies and two care plans are attached here. The case studies have instructions and information needed to come out with the care plans and write them in the respective templates. “ UTI case study Week 6 ” should be filled in the “ Medsurge care plan template ” while “ Week 5 Case Study ” should be done in “ OB Care Plan Template ” Any information needed, I am a text message away please. Thank you ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS medsurge_care_plan_template.docx uti_case_study_week_6.docx ob_care_plan_template.docx week_5_case_study HBU Nursing Student Care Plan Student Name: Unit/RN Admitting Diagnosis: Rm# /Admit Date Past medical/surgical history (PMHx): Age/Gender Co-morbidities: Code Status Date: IV Access Medication Times (circle) (PIV, PICC, PORT, IJ, CVAD etc.) (NPO, Full, Renal, etc.) L: R: Fluid/Rate: Allergies NKDA ? Fall Risk Pre-shift Report: Diet 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 Drains, Devices, Wounds (Foley, JP, Dressings, Restraints, etc). Isolation Blood Type Vaccines Discharge Plan: Teaching: LABS: Date/Result/Interpretation Indicate if high, low, or within normal limits (WNL) Hgb Hct WBC’s Platelets ABG pH PC02 P02 Sa02 Please attach EKG Strip if applicable PT/PTT INR NA+ K+ LFT’s if relevant BUN Cr HgBA1c Glucose Other relevant labs Ordered Diagnostics/Tests 19:00 20:00 21:00 22:00 23:00 00:00 Nursing Assessment Findings/Review of Systems: Chart “by exception.” Neuro/Head/Neck Respiratory (Mucous Membranes, Glasses, Hearing Aids, NVS/ Pupils, Cranial nerves, motor function, Clonus, Seizures, Gait, etc.) (Rate, Rhythm, Pattern, O2 needs, Cough, Trach/Suctioning etc.) Nutrition/Endocrine CV (Diet, % of meals taken, BG/Trends, Tube Feeds, TPN) (Heart Sounds, Pulses, Rhythm, Cap. Refill, Extremities, Pedal Pulses, Weight Attach EKG to back) 1. Priority/Nursing dx. Assessment (as evidenced by) Plan (Goal- short term or GI (Abdomen, Bowel sounds, Bowel Routine, Last BM) GU Integ./MSK/Mobility (Skin, Turgor, Wounds/Incision (s), Hair, Nails, ROM, Safety Concerns e.g. call bell in reach, bed alarm, restraints etc.) Psychosocial (Urinary pattern, Total output, Catheters, Kidney function, Dialysis etc.) (Emotional State, family dynamics, spirituality, pertinent health determinants, Legal/Ethical Issues) Rationale for Goal(s) Intervention (Skills Used/Patient Teaching) Rationale for Goal(s) Intervention (Skills Used/Patient Teaching) Rationale for Goal(s) Intervention (Skills Used/Patient Teaching) long term) Evaluation/Follow Up: 2. Priority/Nursing dx. Assessment (as evidenced by) Plan (Goal- short term or long term) Evaluation/Follow Up: 3. Priority/Nursing dx. Assessment (as evidenced by) Evaluation/Follow Up: Plan (Goal- short term or long term) Pathophysiology Algorithm 1-2 credible (published in the last 5 years and peer reviewed) articles or other credible reference(s) required Etiology that led to the medical diagnosis: Pathophysiology-What is occurring at the cellular/tissue and/or system level? Risk Factors Diagnostic Findings Diagnosis: General Objective/Subjective Clinical Manifestations Relevant DoH (min. 3) and Rationale Complications Gender, health services, environment/working conditions, education and literacy, physical environment, social support networks, personal health practice and coping skills, social environments, healthy child development, biology and genetic endowment, culture, financial and social status General Treatment Treatment for your client Clinical Manifestations of YOUR client (objective/subjective) SCHEDULED MEDICATION WORKSHEET Student Drug Name (Generic & Trade Name) Date Class/Action/ Side Effects Common and SEVERE Dose/ Route/Frequency Is the order within recommended dosing limits? Unit & Room Rationale for your Patient Order frequency & Time(s) you actually gave Lab values/Nursing implications (e.g. if giving K supplement what was the most recent K+ lab? Or if giving insulin what was the blood sugar? HBU Nursing Student Care Plan If giving cardiac meds what is the apical heart rate/vitals?) Week 6 Case Study Dolly Phan is a 75-year-old female who initially came to the ED with uncontrolled urine leakage. Miss Phan reports a 2 week history of incontinence, which she described as “urine comes out even if I emptied my bladder within the hour. When asked to quantify her urine she says it ranges from drops to soaking her clothing. She reports no changes in color other than being embarrassed of having a strong urine odor. Her vital signs were as follows: T 99.3 RR18 HR 68 BP 130/85 She is 6 feet 2 inches tall and weighs 157 lbs (BMI = 20.1) She reports no severe pain other than a dull ache on her lower back. She reports her medications as follows: Prilosec, Lipitor, Plendil and Actonel. In addition she claims usage of Benadryl and Sudafed for a pronounced cold and allergy. She is unable to recall her medication dosages but verbalized she takes them regularly. Miss Phan was in your med-surg unit 3 days later for multiple colonies of bacterial growth on her urine. What age related changes can affect the ability to control urination? What are some medications that contribute to urinary incontinence? How will you verify home medications for Ms. Phan? Describe some nursing strategies for urinary incontinence? Describe functional incontinence? Is urinary catheterization considered as a treatment for functional incontinence? Student Name: Rating Scale CLINICAL PERFORMANCEASSESSMENT WORKSHEET Date: ________________ Subscales 1. ASSESSMENT- Gathered data on the pathophysiology of the illness/disease, medications, culture/spiritual factors, and nutritional status. Incorporated and interpreted new data correctly. Also, gathered information regarding epidemiology & stratification as it applies to client. 2. ANALYSIS/NURSING DIAGNOSIS – Formulated nursing diagnoses for actual & potential health problems relating to health promotion behaviors, growth and development, medications, nutrition, and cultural and spiritual awareness; prioritizes problems according to clients’ needs. 3. PLAN/GOAL – Developed client and family goals that promoted progression toward health. Goals are individualized and SMART (Specific, Measurable, Attainable, Realistic, Time Frame) 4. INTERVENTIONS – Nursing interventions are individualized for the client. Each intervention implements care which reflects planning, organization & flexibility to meet client’s needs that promotes standards of care and practice. 5. RATIONALE – Identified rationale for nursing actions that support the plan of care with current professional literature and research findings. Has significant and complete information regarding health promotion, growth and development, pathophysiology of the illness/disease, medications, nutrition, and treatments; calculates dosage, knows appropriate sites for drug administration, and calculates IV drip rates correctly (if applicable). 6. EVALUATION – Facilitated alteration of care plan to reflect evaluation of client’s progress toward goals; evaluates effectiveness of specific interventions; evaluates ways to maintain standards of care & practice; evaluates criteria that are congruent with clients’ health goals. Applies concepts of health promotion & dimensions of health when evaluating care & client outcomes. Reflections of own performance demonstrates self awareness and identifies areas for growth as well as reflects systematic movement to meet course learning objectives 7. NURSING SKILLS – Performed skills safely & correctly at reasonable speed; adapts to changes from learned sequence; organizes equipment & supplies involved in client care; recognizes obvious breaks in technique.v Efficient in use of technology for client care. Demonstrates use of Presence to promote health and healing. 8. COMMUNICATION – Reported & documented medications, procedures, treatments & changes in client’s condition & client responses to care & interventions. Effectively communicated with clients, staff, & faculty. Maintained confidentiality & adherence to information management policies. 9. PROFESSIONALISM – Prepared to give safe care; adhered to policies & reported own errors; assumed responsibility for maintaining safety; took extra precautions to maintain client’s confidentiality; used appropriate channels to promote a high level of care for the client; selected learning experiences which require additional preparation; demonstrated prudent judgment in unfamiliar situations; was punctual; maintained a professional appearance; promoted the client’s welfare & upheld dignity & professional boundaries; reflected consideration of cultural and spiritual differences when interacting with clients & members of the interdisciplinary team. 10. INTERPERSONAL RELATIONSHIPS – Used communication skills in therapeutic relations; adapted communication to client’s developmental level; promoted positive group & learning activities & staff relations; was able to accurately assess own abilities & began to plan for growth in self.. Reflected consideration of cultural and spiritual differences when interacting with clients & members of the interdisciplinary team. Week ________ Comments Grade . KEY: F= Failing (1); MI = Must Improve (2); A=Acceptable (3); C=Commendable (4); and E=Excellent (5) Houston Baptist University NURS 4434 Care of Childbearing Family Antepartum Care Worksheet Student Name EDC Date Wks Gestation Pt’s Initials Room Age GTPAL Current Wt Allergies Pre-Pregnancy Wt Marital Status Pre-shift Report: Test and result/date Blood type Rh factor Antibody screen Hgb Hct WBCs Platelets Test and result/date Rubella HIV RPR/VDRL HbSAg Gonorrhea Chlamydia GBS Interpretation of abnormal lab results: HBU Nursing Student Care Plan Reason for hospitalization: Medical Diagnosis: Steroid Doses and Dates: Diet: Activity: Discussion of medical diagnosis. What are signs and symptoms, etiology, diagnostic tests used, current treatment/medication orders, possible emergency states and medical interventions. Brief pregnancy history and any prior obstetric history. Fetal monitoring frequency: Time FHR: Monitor Mode Monitor mode E = External I = Internal FHR Baseline FHR Variability FHRV ++ = marked + = moderate – = minimal 0 = absent Maternal Vital Signs Time BP T P R Accelerations Deceleration Type Accelerations ++ = 15 X 15 0 = none Voided/ catheter Hourly IV rate Monitor Mode Decelerations E = Early decelerations V = Variable deceleration L = Late deceleration P = Prolonged deceleration Duration Frequency Intensity _____ mmHg Mild= mild Mod= moderate Str= strong Medications Maternal given Position Pain Intensity Resting Tone Resting Tone: _____ mmHg Soft = soft Mod = Moderate H = Hard Other (DTRs, clonus..) Discuss family configuration, cultural/spiritual assessment, and financial/emotional health. Prioritized Problem List/Nursing Diagnoses, R/T and AEB: (two for Mom and one for baby): This section is for any additional evaluation of yourself that you may want to share with the instructor Nursing Skills: Strengths: Opportunities for Improvement: Comments: Initial Assessment Data r/t Priority Nursing Dx: Rationale for Nursing Dx #1: 1. 2. Highest Priority Nursing Dx: 3. 4. Plan: Short Term/ Long Term Goal: 5. Interventions: Evaluation: 1. 2. 3. 4. Skills Used for this Nursing Dx: 5. Explore potential Legal/Ethical Issues r/t caring for patient: Safety Concerns when caring for this patient: Rationale for Nursing Dx #1: Initial Assessment Data r/t Priority Nursing Dx: 1. 2. 3. Highest Priority Nursing Dx: 4. Plan: Short Term/ Long Term Goal: 5. Interventions: Evaluation: 1. 2. 3. Skills Used for this Nursing Dx: 4. 5. Explore potential Legal/Ethical Issues r/t caring for patient: Safety Concerns when caring for this patient: Houston Baptist University NURS 4434 SCHEDULED MEDICATION WORKSHEET Student __________________________________ Date______________________________ Unit & Room ______________________________ Drug Name Class/Action (Generic & Trade Name) Side Effects Dose/ Route Recmd dose Rationale for your Patient Frequency & Times Military Time You Will Give Lab values/ Nursing implications Anti-partum Case Study Mother G1P0 34.5 artificial rupture of the membranes clear. Mother is 40 years of age and had IVF Vital signs q4h. FHR tracings were ruled category 1, TOW showed contractions. No cervical dilation at this time. Tocolytics given to stop contractions. What kind do you think they will give? Beta-mimetics Magnesium Sulfate given 6gm loading dose 2gm every 12 hours with 1000mg lactated ringers. (fatal protection) Why? Both mother and baby will have Q4 VS. Complete assessment of mother and baby (cite sources). Write down 3 priority nursing diagnoses for mom and 3 priority nursing diagnoses for baby. Care plan for mother and baby. Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby. Cite where you got this information. …HBU Nursing Student Care Plan Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10