NURS101L Nursing Care Plan Template Paper I will be providing the nursing care plan template. I need everything listed in the template to be followed. Also

NURS101L Nursing Care Plan Template Paper I will be providing the nursing care plan template. I need everything listed in the template to be followed. Also need citations after everything and will be providing the two textbook names. Please complete very thoroughly thank you. Instructor
FUNDS N101L
SPRING 2016
FUNDAMENTALS SCENARIO
for CAREPLAN
PATIENT INFORMATION: Ms. Florence Nightingale, African-American 80 year-old female who is
alert and oriented x 4. She presents here to Utopia Hospital via AMR due to an un-witnessed fall at
home. She currently lives alone fully independent with her 3 cats. She has two sons (both live out of
state) and one daughter who lives doors down from her mother’s home. She is an active woman
who attends church every Sunday, watches her 3 grandchildren every Tuesday and Thursday after
school, and plays bridge with the “red hat ladies” on Wednesday evenings at the YMCA. She is
widowed as of three years ago and was married for 60 years. She is a retired professor of Nursing
and states, “I am enjoying retirement very much – staying active is important to me”. She ambulates
with a walker in the house and out.
PATIENT HISTORY: HTN, CHF, Atrial Fibrillation, COPD, GERD, DVT in 2013 for which she was
hospitalized at Utopia. She quit smoking 3 years ago. She was a one-pack-a-day smoker for 50 years.
She does not consume alcohol or take illicit drugs. Ms. Nightingale is DNR. Patient is allergic to
penicillin and cashews.
HISTORY OF PRESENT ILLNESS: Ms. Nightingale has been admitted to Utopia Hospital via AMR for
an un-witnessed fall at home. She states, “I tripped over my cat and fell on my left side”. She called
her daughter who proceeded to call 9-1-1. Ms. Nightingale states, “I did not lose consciousness”.
Vital signs upon arrival to the ER were: BP 130/80, P 116, RR 24,02 sat 92% room air, T 99
degrees F, Wt 125 pounds, Ht 62″. Lower left lobe crackles on auscultation. She complains of pain
9/10 in her left hip and left thigh. She has a visible bruise measuring approximately 3 x 3″ on her
lateral left thigh with no skin breakdown or open wound. She presents with bilateral lower
extremity edema with 2+ pitting. She states that it is normal for her to have swelling in her ankles.
She complains of difficulty urinating and has been getting up at night to urinate. She states that she is
“mildly” incontinent and has been wearing pads. She has a 20-guage IV catheter in her right AC
infusing 0.9% NS at 25 mls/hr TKO. No signs of redness, edema, or infection.
ORDERS: She has been placed on 2 L 02 NC bringing her oxygen saturation rate to 97%. Patient is
NPO for pending surgery. Bed-rest and non-weight-bearing status ordered. Respiratory Therapy
order PRN. Morphine 2 mg/ml IVP q2 hours PRN for pain
PATIENT HOME MEDICATIONS:
warfarin 4 mg PO q day, metformin 1000 mg PO q day, furosemide 20 mg PO qday, metoprolol
100
mg PO qday, ibuprofen 400 mg PO qday PRN, Tums 12+ PO qday PRN
DIAGNOSTICS: 1/1/16, 0800, X-ray findings consistent with left accetabular hip fracture;
additionally full complete fracture of left femur.
Labs: 1/1/16 0900, Glucose Finger Stick = 310, WBC 12,000, HGB 13, HCT 55%, RBC 4.0, PLTS
300,000, NA+ 150, K+ 3.1, CL-106, BUN 30, CREATININE 1.6, HgbA1c 8.2 %, INR 2.5, PT 12
.
NOTE TO STUDENTS:
This is an opportunity to think like a nurse’ – the care plan is a process and a way that we
deliver quality healthcare.
Only one ‘dot com’ reference; the rest should be books (Potter & Perry) and/or nursing
journal articles.
Please do not copy content from above ‘word for word’
APA formatting to include title page and reference page
In-text citations
No Wiki, WebMD, Taber’s, or dictionary
.
.
Reference from books
PLAN
NANDA-APPROVED NURSING DIAGNOSES 2018-2020
Grand Total: 244 Diagnoses
August 2017
Indicates new diagnosis for 2018-2020–17 total
Indicates revised diagnosis for 2018-2020–72 total
(Retired Diagnoses at bottom of list-8 total)
Credit line listed in the book:
NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018-2020, 11th
Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru.
© 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, New
York. Companion website: www.thieme.com/nanda-i.
1. Activity Intolerance (p. 228)
2. Activity Intolerance, Risk for (p.229)
3. Activity Planning, Ineffective (p. 322)
4. Activity Planning, Risk for Ineffective (p. 323)
Acute Substance Withdrawal Syndrome (p.351)
6. Acute Substance Withdrawal Syndrome, Risk for (p. 352)
7. Adaptive Capacity, Decreased Intracranial (p. 357)
8. Adverse Reaction to lodinated Contrast Media, Risk for (p. 429)
9. Airway Clearance, Ineffective (p. 384)
10. Allergy Reaction, Risk for (p. 430)
11. Anxiety (pgs 324-325)
12. Aspiration, Risk for (p. 385)
13. Attachment, Risk for Impaired (p. 289)
14. Autonomic Dysreflexia (pgs. 353-354)
15. Autonomic Dysreflexia, Risk for (pgs 355-356)
16. Bathing Self-Care Deficit (p. 243)
17. Behavior, Disorganized Infant (pgs 359-360)
18. Behavior, Readiness for Enhanced Organized Infant (p. 362)
19. Behavior, Risk for Disorganized Infant (p. 361)
of
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