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 Scale2 Table of Contents3 Summary Page4 Client’s Clinical Picture (Cephacaudal Assessment)5 Medical Diagnosis6 Textbook Description of Disease6-12 Treatments and Procedures13 Summary of Caregiver Progress Notes14 Diagnostic Values Out Of Normal Range Clinical Implications16 Medications18-52 Holistic Nursing Care Plan Form53-62 List of Nursing Diagnosis65 Five Nursing Diagnoses66-70 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 ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. ...
