CPNP 108 - Nursing Care Plan (Format)  Assignment:      Patient Demographic: Past Medical & Social History Family Situation Patient's Issues or challenges (Actual / Potential) Medical Diagnosis Signs & Symptoms Lab Values Medications Client Strengths   Growth & Development Stage (according to Eric Erickson's theory)   2 (Actual) Nursing Diagnosis   1 (Potential / Risk) Nursing Diagnosis   2-3 Goals for each Nursing Diagnosis Short-term (Client focused) Long-term (Client focused)   2-3 Nursing Interventions for each Goal and Rationales 1st Intervention should include assessing / assessment of the client for the specific issue

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CPNP 108 - Nursing Care Plan (Format) 

Assignment: 

 

 

• Patient Demographic:
• Past Medical & Social History
• Family Situation
• Patient's Issues or challenges (Actual / Potential)
• Medical Diagnosis
• Signs & Symptoms
• Lab Values
• Medications
• Client Strengths

 

• Growth & Development Stage (according to Eric Erickson's theory)

 

• 2 (Actual) Nursing Diagnosis

 

• 1 (Potential / Risk) Nursing Diagnosis

 

• 2-3 Goals for each Nursing Diagnosis
• Short-term (Client focused)
• Long-term (Client focused)

 

• 2-3 Nursing Interventions for each Goal and Rationales
• 1^st Intervention should include assessing / assessment of the client for the specific issue.

 

• Evaluation for each Goal
• Should include a specific timeline mentioned in the evaluation.
• For example: The client will demonstrate ......... by the end of the shift, every 15 minutes, every hour or by a specific date.
• About the Client.

= Born June 12, 1943 in galahand AB, small town.  have 1 sister in Calgary, She was in Galahand until she was 10 and moved to Calgary. LIved in US, BC.  She was 24 when she got married and now divorced with 2 kid, daughter is in Alaska and son is in Hawaii.She has 5 grandchildren, most important in her life are her kids.  BS Psychology graduate, worked for 10 years as Psychologist.Her achievement is her degree and her children.Raised as Protestant, God is important to her  and she likes to read, watch TV .  used to play piano, and she loves crafts

• Influenza A virus (RNA) NAT- Negative
• Influenza B virus (RNA) NAT - Negative
• Covid-19 Test - Negative
• Blood Chemistry- Low
• CBC- Low

Medications  Apo- Acetominophen (Tylenol) for pain   1 tab 500 mg TID Apo- metroprolol (Toprol XL) for hypertension  1 tab 25 mg BID Jamp- hydralazine (restoralax) for constipation ( 1 tab 10 mg TID Jamp-emolax powder for constipation 17g/dose Sandoz (candesartan) for hypertension 1 tab 30 mg OD Siv- escitalopram(Cipralex) treat anxiety disorder or depressive disorder 1 tab 10 mg OD Diltiazem (Cardizem) treat highblodd pressure, angina 1 cap 200mg OD Xarelto/Rivaroxaban 1 tab 20 mg OD PRN- Bowel protocol- PEG 3350 17g-day 2- no BM after 48 hrs give oral laxative senna 2 tabs PO OD PRN- Lidodan ointment GM apply topically to both feet twice as needed for pain, interdry to all affected folds