WEST COAST UNIVERSITY Course Number and Name Course: NURS 210L-AB NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 317L Student Date Instructor Course Patient Initial Unit/ Room# DOB Code...

WEST COAST UNIVERSITY
Course Number and Name
Course: NURS 210L-AB
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
    Student
    
    Date
    
    Instructo
    
    Course
    
    Patient Initial
    ABC
    Unit/ Room#
    
    DOB
    
    Code Status
    
    Height/Weight
    
    Allergies
    
    Temp (C/F Site)
    Pulse (Site)
    Respiration
    Pulse Ox (O2 Sat)
    Blood Pressure
    Pain Scale 1-10
    97.5 F (36.4C) Tympanic
    81 Radial
    17
    88% room ai
    170/111
    0
    History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations
    Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
    
Admission Dx: HF Exace
ation
Chief Complaint: Shortness of Breath
Present Illnesses: Hypertension: Persistent A fi
illation
Obesity: Extreme amount of adipose tissue or body fat. Dyspnea or difficulty in
eathing on exertion (Malema, 2021).
Moderate Chronic Obstructive Pulmonary Disease (COPD): Progressive disease recognized by constant airflow limitation (Rossi et al., 2017). Increased chronic inflammatory response in the respiratory organs i.e., windpipe and lungs.
Chronic Systolic Heart Failure: Incapability of the heart to pump blood properly. Loses the ability to produce required amount of pressure to push blood forward through the aorta (Mitchell, 2018).
Mitral Valve Annulus Heart Failure: Incapability of the heart to generate sufficient blood cells to satisfy the oxygen requirements of organs and tissues. The low cardiac output leads to decreased functional ability, fluid volume imbalance, impaired gas exchange and diminished tissue perfusion (de Enfermagem & de Enfermeira).
    • GENERAL Well developed, acute distress not found.
Clean appearance. Speaks short one-word answers
• NEUROLOGICAL Patient Ao4, 456; grip equal and strong
ilateral, Pupils PEERL
• cardiovascular A-fi
illation, murmur diagnosed, pulses +2 (pedal
and radial) cap refill in <3 sec
• Respiratory RR 28, crackles in bases, Abdominal and shoulder
etractions diagnosed
• Musculoskeletal ROM within normal range, no
prosthetics, ambulatory
• Gi 16f Foley catheter inserted date of assessment 500ml
present clear yellow, sediments not noted
• GULast BM today, soft,
own
• INTEGUMENT Skin intact, BLE ruddy with +2 pitting
edema
• ACTIVITY Tolerable
    Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
    Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
    B NATRIURETIC PEPTIDE (BNP) 7910.0 H
Troponin I 0.009 ng/mL
PT 14.5 H sec
PT Mean 12.8 sec
INR 1.2
PTT Mean 29.5 sec
PTT 39.7 H sec
GLUCOSE 235 mg/dL
UREA NITROGEN 15 mg/dl
CREA 0.89 mg/dL
EGFR 82.9 mL/min
PROTEIN, TOTAL 6.5 g/dl
CALCIUM 8.4 L mg/dl
ALBUMIN (LX) 2.7 L G/dL
SODIUM 136 mEq/L
POTASSIUM 3.8 mEq/L
CHLORIDE 98 mEq/L
ANION GAP 10 mmol/L
CO2 28 mEq/L
BILIRUBIN TOTAL 1.3 mg/dL
DIGOXIN 1.3 ng/ml
WBC 8.97
RBC 4.41 MIL/cmm
HEMOGLOBIN 11.9 L g/dL
ALK PHOSPHATASE 115 IntUnit
AST 20 IntUnit
ALT 21 IntUnit
CPK 28 IntUnit
HEMATOCRIT 39.6 %
MCV 89.8 fL
MCH 27.0 L pg
MCHC 30.1 L g/dL
RDW-CV 16.3 H %
RDW-SD 53.9 H
PLATELET 227 K/cumm
MPV 10.3 fL
NEUTROPHIL 81.5 H %
NEUTROPHIL 5.68 K/mcL
LYMPHOCYTE 8.3 L %
LYMPHOCYTE 0.58 L K/mcL
MONOCYTE 8.3 %
MONOCYTE 0.58 K/mcL
EOSINOPHIL 0.9 %
EOSINOPHIL 0.06 K/mcL
BASOPHIL 0.7 %
BASOPHIL 0.05 K/mcL
IMMATUREGRANULOCYTE 0.3 %
IMMATURE GRANULOCYTE <0.03 K/mcL
NUCLEATED RBC 0.0 /100WBC
NUCLEATED RBC <0.01 K/mcL
EKG: Paced rhythm rate of 83 bpm
Radiology: Right lower lobe infiltrate unchanged from prior on
preliminary pending final read by radiology.
CXR: Shows right lower lobe infiltrate. Lower suspicion for
pneumonia.
    Post-traumatic stress disorder – this disorder is mental health condition and any te
ifying event is capable of causing this trauma. Certain symptoms are nightmares, flashbacks, uncontrollable thought process on certain events and severe anxiety attacks (Gieselmann et al., 2019).
Atrial fi
illation – this is an i
egular and...