Clinical Settings of the Holistic Nursing Care Plan

Clinical Settings of the Holistic Nursing Care Plan

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Course NUR 1210L Instructor Dates of Care 12, 13, 19 20 Sept 96Date Submitted 111596Student Names  SNSPJCHOLISTIC NURSING CARE PLANSTUDENT Anthony BernardiGRADEDATE November 15, 1996Clients Clinical Picture (5)(Initial Cephacaudal assessment)Textbook Description of Diagnosis (5)Summary of Clients Progress (5)Completion of Holistic NCP Tool (30)NURSING DIAGNOSIS (15)GOALS (10)INTERVENTIONS (10)RATIONALES (5)EVALUATIONS (10)REFERENCES (5)TABLE OF CONTENTSSUBJECT PAGE Cover Page 1 Grading Point Scale 2 Table of Contents 3 Summary Page 4 Clients Clinical Picture (Cephacaudal Assessment) 5 Medical Diagnosis 6 Textbook Description of Disease 6-12 Treatments and Procedures 13 Summary of Caregiver Progress Notes 14 Diagnostic Values Out Of Normal Range Clinical Implications 16 Radiology 17 Medications 18-52 Holistic Nursing Care Plan Form 53-62 List of Nursing Diagnosis 65 Five Nursing Diagnoses 66-70 References 71CLIENT CLINICAL PICTUREPlease see attached Cephacaudal Assessment (Pages 5)MEDICAL DIAGNOSIS Current diagnosisNecrotizing pneumonia, cachexia secondary to malnutrition infection, hypothroidism, NIDDM, empyema RUI, Aspergilloma, RUI, and depression. HX HTN, atrial fibrillation, COPD, asthma TEXTBOOK DESCRIPTION OF DIAGNOSISSee attached Disease Process Description (pages 6-12-)SUMMARY OF CAREGIVER PROGRESS NOTES See attached Caregiver Progress Notes (page 14-15)CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 61896. for atypical chest pain and hemoptysis. VS BP 11451, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who…

Clinical Settings of the Holistic Nursing Care Plan