[Solved]: Nursing Care Plan- Basic Conditioning Factors Patient…

Nursing Care Plan- Basic Conditioning Factors Patient identifiers: Age: Gender: Ht: Wt. Code Status: Isolation: Development Stage (Erikson): Give the stage and rationale for your evaluation Health Status Date of admission: Activity level: Diet: Fall risk (indicate reason): Client’s description of health status: Allergies: (include type of reaction) Reason for admission: Past medical history that relates to admission: Socio-cultural Orientation Religious, Cultural and Ethnic background with current practices: Socialization: Family system (support system): Spiritual: Occupation (across the lifespan): Patterns of living (define past and current): Barriers to independent living: Rasmussen University School of Nursing Nursing Care Plan 2 ALLERGIES: Sulfonamides (sulfa ) Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following: 1: What is the Mechanism of Action; 2: Why is the client taking the medication? Medication Classification Dosage & Route Rationale Possible Negative Outcomes Rasmussen University School of Nursing Nursing Care Plan 3 CONCEPT MAP . Pathophysiology – (to the cellular level) Medical Diagnosis Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies). What symptoms does your client present with? Complications Treatment (Medical, medications, intervention and supportive) Risk Factors (chemical, environmental, psychological, physiological, and genetic) Nursing Diagnosis Problem statement (NANDA diagnosis): Related to (What is happening in the body to cause the issue?): As evidenced by (Specific symptoms): Rasmussen University School of Nursing Nursing Care Plan 4 LAB VALUES AND INTERPRETETION LAB Range Value V a l u e MEANING (If WDL then explain the possible reason for the lab) LAB Range V a l u e Value MEANING HEMATOLOGY CHEMISTRY CBC Glucose 70-110 268 WBC 4.80-10.80 8.92 BUN 7-28 19 RBC 4.20-5.40 4.50 Cr 0.44-1.32 0.97 HGB 12.0-16.0 10.8 GFR >60 54 HCT 37.0-47.0 36.1 Na 138-147 138 PLATLETS 150-400 292 K 3.6-5.0 5.0 Diff: CO2 18-30 27 Polys Ca 8.7-10.7 9.3 Bands Phos Lymph 21.9 Amylase Mono 7.7 Lipase Eosin 5.3 Uric Acid GBC indices Protein MCV 81.0-99.0 80.2L Albumin MCH 27.0-33.0 24.0 Cl 99-110 104 MCHC 32.0-36.0 29.9 Enzymes COAGs LDH PT CPK INR SGOT PTT SGPT ABGs (V or A) Troponin I PH Myoglobin PCO2 PO2 Cholesterol BASE EX: SAT: Rasmussen University School of Nursing Nursing Care Plan 5 URINALYSIS Range Value Meaning Others not listed: Findings Meaning Color YELLOWDARK YELLOW YELLOW Gastroccult Clarity CLEAR CLEAR Hemoccult Sp. Gravity 1.005-1.030 1.014 pH 4.0-8.0 6.0 EKG Protein NEGATIVE TRACE Glucose NEGATIVE 250 CT Scan Ketones NEGATIVE NEGATIVE Bilirubin NEGATIVE NEGATIVE Occ. Blood NEGATIVE NEGATIVE MRI or MRA Urobilinogen 0.2-1.0 0.2 WBC NONE-5 110 RBC NONE-5 NONE Epithelia NONE-FEW NONE Ultrasound WBC RBC Epith Cell Bacteria NONE SEEN NONE SEEN Hyaline Cast NONE -3 2 Gran Cast Bedside Procedures: Leukocytes NEGATIVE LARGE Nitrite NEGATIVE NEGATIVE ACCUCHECKS Rasmussen University School of Nursing Nursing Care Plan 6 Additional information: Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment fin