Dates of Care: 12, 13, 19 & 20 Sept 96 Student Names: Anthony Bernardi, SN/SPJC HOLISTIC NURSING CARE PLAN Client’s Clinical Picture (5) (Initial Cephacaudal assessment) Textbook Description of Diagnosis (5) Summary of Client’s Progress (5) Completion of Holistic NCP Tool (30) NURSING DIAGNOSIS (15) INTERVENTIONS (10) EVALUATIONS (10) SUBJECT PAGE # · Grading Point Scale 2 · Table of Contents 3 · Client’s 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 · Medications 18-52 · Holistic Nursing Care Plan Form 53-62 · List of Nursing Diagnosis 65 · Five Nursing Diagnoses 66-70 Please see attached Cephacaudal Assessment (Pages 5) MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia, cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI, Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma
TEXTBOOK DESCRIPTION OF DIAGNOSIS:
See 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 6/18/96. for “ atypical chest pain and hemoptysis”. V/S BP 114/51, 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 ( wast...
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