Use the blank care plan document that I sent to complete with the information related to the patients.USE the blank document twice because I need the Kyler miller care plan separate to the Sacramento john care plan . Read the patient’s conditions in the documents and complete the two separate care plans with the information. I sent too a care plan example with the requirements needed
Patient Name: Sacramento John
MedSurg Unit
52 year old white male, came to the Emergency department ? severe abdominal pain,
nausea, vomiting over the last 2 days. Since yesterday evening, the patient reports
feeling dizzy and weak. The patient thought it was the flu-like symptoms, but came to
the ED due to stomach pain becoming worse.
The patient reports that he is a widower, who practices Mormon faith. The patient
denies cigarette smoking and alcohol consumption. The patient denies any past medical
history or surgeries. In the ED, the nurse reports that the patient vital signs were as
follow: T 99 (oral); P 130 bpm, strong, regular; R 18 bpm, regular, labored; O2 sat 90%
room air; BP 108/78 sitting, left arm; Pain= 10 +/10. The skin color was pale with poor
turgor, oral mucosa dry and pasty and abdomen distended.
The consent forms for treatment are signed.
Lab results:
BMP: Na 150
CBC: Hb 20
Creatinine 1.9
HCT 60
Cl 108
WBC 17
BUN 42
Using SBAR format, please give report to the on-coming nurse.
Thank You
PATIENT CARE PLAN GUIDELINES
STUDENT: PROCESS I
INSTRUCTOR: A. SMITH
SLO# 1-Explain questions,
problems, and/or issues
PATIENT INITIALS: JD
AGE:50
M/ F– M
SLO# 2-Analyze and interpret
relevant information
NANDA DX AND
STATEMENT:
Nursing DX:
NANDA)
Ineffective Airway
Clearance
Related to
Poor
cough effort
As manifested by
Subjective Data:
(What patient states)
Objective Data:
(Measurable Data that
observe: see/ hear/
smell/ feel)
Must have at least
three, but try for more
1.
2.
3.
4.
?
1.
2.
3.
4.
5.
ADMITTING DX: PNEUMONIA
ADMISSION DATE: 8-25-04
SLO# 2-Analyze and interpret
relevant information
STG & LTG GOALS:
NURSING INTERVENTIONS
Goals must be:
Measurable
Observable
Timed
Realistic
Specific
Nursing actions to be
performed:
? Must include one Short
and Long term goal
o Short term goals are
within 24 – 72 hours
o Long term goal are
by discharge date
SLO# 3-Evaluate
information to determine
potential conclusions
SLO# 4-Generate
a well-reasoned
conclusion
RATIONALES
EVALUATION:
GOALS MET?
? Rationales are the
reasons for the
interventions
Determine if
goal is met if
possible
Tailored to patient
? Source must be
Can be interdependent,
documented using
independent, dependent
APA format
Should have 9
(Cox, p.90)
interventions-include (3)
assess, implementation,
and teaching for each
nursing diagnosis
Use textbooks for
resource
Should be patient
centered.
Patient will
(verbalize, choose,
apply, state, move)
What would
you change?
Develop an
alternate plan.
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attachment
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