Tahmida hossain

Here is one of sample careplan that i did in my clinical experience:Herzing University Brookfield/ Kenosha Adult Health Care Plan Template

Student Name: _Tahmida_______ Hossain____________ _____________ Unit: ____ In-depth Final care plan______Adult Health 1________________

Date _03/15/13______________

1. Nausea r/t gastritis as evidence by loss of patient’s appetite and reports of dyspepsia.

2. Fatigue r/t diseases states as evidence by activity intolerance

3. Anxiety r/t diminished health status as evidenced by self care dependencies, weakness, and future health care management.

Assessment Priority
Nursing Diagnose Goals/Outcomes
List at least 2
(must be time-sensitive, measurable, & realistic) Interventions to Implement-relate to numbered Outcome
At least 3-5
(Must be specific, realistic, and measurable) Rationale
Must use APA references and have at least two different sources Evaluation-relate to numbered Goal/Outcome
Subjective: Patient said “I don’t like to eat because I feel nausea all the time.”
Patient stated “I feel burning inside of my tummy.”
patient said “ I feel tired and lack of energy after I do the long and fast exercise in P.T”
Patient said “ I fear of being sick and not be able to do the things I used to do”
Patient said “food smell and other odors make me feel nauseous.”

Objective:
NKA
A*0*3 pupils are equal, round and reactive to light. . Warm and dry skin. Bilateral Hand grasp 2+
Distal and radial pulses are intact. 2+ bilaterally.
Patient has hyperactive bowel sounds and soft abdomen.
V/S
BP 137/67
Spo2 98%
Height 5 feet 3 inches. Weight 207 lb.
BMI 35.8
HR:61
T. 97.9
R: 20/ min
Skin turgor less than 2 seconds.
In capillary refill, color came back within 3 seconds.
Lung sound: wheezing bilaterally, lower lung. Heart sound: no audible murmur or s3 s4 sounds.
Patient has 3 different round , hard 2 cm lesions on her head. Bilateral Hearing and vision test passed.
Patient has bilateral pitting edema. 2+
Patient walks with walker with assistant only.

Lab:

Uric acid 5.2 2/27
Potassium 3/3
HGB 11.8 2/27
Albumin 3.0 2/27
Urine
UCR 107.06
UPH 5.0
USPG 1.023
U bacteria: none seen