(Solved) NSG125 Transition to Professional Nursing- Care Plan | Homework Solution

NSG125 Transition to Professional Nursing- Care Plan

Instructions:

During the NSG125 Transition to Professional Nursing course, students will complete a total of one care plan assignment as follows:

  1. Care Plan based on a simulated client case from Shadow Health – OR
  2. Care Plan based on a clinical site client.

Care Plan Map Components:

  • Part I: Physical Assessment
  • Part II: History & Physical
  • Part III: Medications
  • Part IV: Diagnostic Studies & Interpretation/Assessment Explanation
  • Part V: Clinical Judgement Measurement Model Table

Rubric: Must achieve 16 points to pass clinical.

  1. Care Plan based on a simulated client case- OR a Care Plan based on a clinical site client
Criteria 4 points 3 points 2 points 0 points Total Points
Part I: Physical Assessment All components of the physical assessment are present. Most of the information is provided with all areas addressed. No more than 3 missing areas. No more than 6 of the assessment areas are lacking information. Assessment information not provided  
Part II: History & Physical Information is complete and accurate; All areas of the section are addressed. Most of the information is provided with all areas addressed. No more than 3 missing areas. No more than 6 of the history & physical areas are lacking information. Assessment information not provided  
Part III: Medications Information is complete and accurate; All areas of the section are addressed. Most of the information is provided with all areas addressed. No more than 3 missing areas. No more than 6 of the history & physical areas are lacking information. Assessment information not provided. Transition to Professional Nursing- Care Plan  
Part IV:                        

Diagnostic Studies & Interpretation/Assessment Explanation

Information is complete and accurate; All areas of the section are addressed. Most of the information is provided with all areas addressed. No more than 3 missing areas. No more than 6 of the history & physical areas are lacking information. Assessment information not provided  
Part V: Clinical Judgement Measurement Model Table Information is complete and accurate; All areas of the section are addressed. Most of the information is provided with all areas addressed. No more than 3 missing areas. No more than 6 of the history & physical areas are lacking information. Assessment information not provided  
Total points /20

NSG125 Transition to Professional Nursing- Care Plan

Part I: Physical Assessment

VS Time:          Temperature                       Pulse             Respirations                          BP          /                          Pain    /10

VS Time:          Temperature                       Pulse             Respirations                          BP          /                          Pain    /10

GENERAL SURVEY
Age___________           Male/Female/Other         Body Build:   WNL    Muscular    Obese     Thin      Cachectic

Height___________  Weight____________                      Well-groomed         Poorly Groomed

Facial Expression:   Content     Happy     Anxious    Sad     Angry    Flat

NEUROLOGICAL
(LOC) Level of

Consciousness

Alert      Awake      Lethargic      Obtunded       Stupor      Comatose      Confused

Transition to Professional Nursing- Care Plan

Oriented x 4:

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If not alert X 4, circle what they are alert to:  Person      Place     Time     Situation

 

Eyes Unaided sight        Glasses      Contact lens       Blind
Pupils Equal        Round       Reactive to light      Accommodates      List abnormal findings:________________________________________

Pupil reaction: Brisk   Sluggish   Nonreactive to light

Pupil size:    before light ______mm          after light ______mm

Ears Unaided hearing       Hard of hearing        Deaf        Hearing aid         Implant
Extremity Strength Hand  grips    +1 +2 +3 +4 +5     equal  unequal

 

Foot pushes     +1 +2 +3 +4 +5    equal  unequal

 

Pain Location:

 

Onset (when did it start):

 

Provokes (makes it worse):

 

Palliates (makes it better):      

 

Quality (description):

 

Radiate:             location:

 

Severity:  ___/10

 

Time:  Constant   Intermittent

CARDIOVASCULAR
Skin / Mucous Membranes Normal for Ethnicity        Pallor         Cyanotic          Jaundiced               Ruddy                 Flushed              Diaphoretic
Radial and Pedal Pulses Radial: Right: Strong  Weak  Thready  Absent   Left:  Strong  Weak  Thready  Absent

 

Pedal:  Right: Strong  Weak  Thready  Absent   Left:  Strong  Weak  Thready  Absent

Apical Radial Pulses (2 assessed simultaneously)    Equal                          Pulse Deficit
Capillary Refill Normal (<3 Sec)                ______sec Location:________________
Edema Absent             Present: location                       +1 +2 +3 +4      Non-Pitting
Heart Rhythm/

Sounds – S1S2

Heart Rhythm: Regular       Irregular

 

Heart Sounds: S1/S2     Murmur        Extra Sounds

 

Sound: Strong         Distant

 

IV None

Solution_______________      Rate ____ml/hr

Site location (be specific)                ______________________________________

Site appearance:  WNL    Edema     Erythema      Tender      Pallor

Dialysis access: type __________       Thrill     Bruit     Location:___________  Appearance:____________

RESPIRATORY
Respirations Pattern: Regular   Irregular

 

Effort: Unlabored     Labored     Nasal flaring    Sternal retraction    Intercostal retraction

 

Chest Expansion: Symmetrical    Asymmetrical

Lung Sounds Anterior : Clear______    Wheezes______   Crackles ______   Rales______   Rhonchi______  Diminished______

 

Posterior: Clear______    Wheezes______   Crackles ______   Rales______   Rhonchi______  Diminished______

 

Cough None     Non-productive      Productive      Sputum: amount          color
Oxygen Room air       O2 at_____L/min

Nasal Cannula         Oximizer       Simple Mask     Partial Re-Breather Mask       Non-Rebreather Mask

Respiratory Treatments Incentive Spirometer (IS): ml______ # of times______

Nebulizer:_____________    Inhalers:______________     Flutter Valve:_______________

GASTROINTESTINAL
Oral Mouth: Teeth      Dentures      Caries

 

Swallowing:  Gag reflex     Dysphagia

 

Mucous Membranes:     intact     moist     dry     pale    pink

Abdomen:

 

Contour: Soft      Round     Flat     Scaphoid     Obese

 

Palpation: Firm     Hard     Tender    Non-Tender   Location:

 

Distention: Nondistended     Distended

Bowel Sounds RLQ            Normoactive     Hypoactive     Hyperactive      Absent

 

RUQ           Normoactive     Hypoactive     Hyperactive      Absent

 

LUQ           Normoactive     Hypoactive     Hyperactive      Absent

 

LLQ            Normoactive     Hypoactive     Hyperactive      Absent

NG/ GT/ JT None

Type of tube _____      patent                           non-patent

Purpose:   Suction       Feeding       Medication Administration

 

Type of food: _________  Fluid Flush__________mL

 

Bowel Movement Continent          Incontinent

 

Last BM__________      Color                  Consistency

 

Ostomy:   yes  no

Nutrition Self-feed           Needs assistance

Diet___________    % eaten Breakfast_______ Lunch________             NPO_________ if yes, why?___________

Thickened liquids:  honey  nectar    pudding   Food Consistency:  Regular    Mechanical Soft     Pureed

Transition to Professional Nursing- Care Plan

Tube Feed: Yes or No

 

GENITOURINARY
Urine Continent        Incontinent

Urgency     Hesitancy     Frequency     Burning    Nocturia

Catheter type _______________   None

Color_________________  Clear      Cloudy      Sediment        Burning         Frequency

Transition to Professional Nursing- Care Plan

Intake and Output PO/Oral/Tube Feed intake____________ mL

IV intake____________  mL

Urine output_________   mL

Other output_________ mL

Fluid restriction ___________mL/day

Transition to Professional Nursing- Care Plan

MUSCULOSKELETAL
ROM Active ROM: Completed____________             Passive ROM: Completed____________
Mobility Ambulatory assistance:  Independent     Gait belt    Cane     Walker     Crutches     Wheelchair

Transition to Professional Nursing- Care Plan

Walks:  distance                 frequency                 tolerance                   PT  OT

Other Musculoskeletal Cast:               Location:

 

Brace:            Type:            Location:

 

Amputation:            Location:

 

Risk for Falls Bed alarm        Chair alarm       1 or 2 Person Transfer        Floor mat        Side Rails         Mechanical Lift         Slide Board
INTEGUMENTARY
Appearance Color: Normal for Ethnicity    Pallor      Rash      Bruise     Lesions

Intact  

OR

Non-Intact: Location of Non-Intact Areas_____________________________________________________

New Scars:   Location _________________________

Dressing change: (describe: location, steps, drainage, wound)

Transition to Professional Nursing- Care Plan

Temperature and Moisture Temperature:        Warm          Hot          Cool             Cold

 

Moisture:     Dry             Moist

Transition to Professional Nursing- Care Plan

Incisions/Wound None

Surgical site – Location                          Incision Edges: Well-approximated Sutures    Staples   Steri-strips

Dressing:   Dry/intact   Non-intact    Change:  yes  no

Drainage: Color                            Amount___________                       Odor_________

 

Wounds

Location:                  Wound appearance                         Tunneling              Eschar               Slough

Location:                  Wound appearance                         Tunneling              Eschar               Slough

Location:                  Wound appearance                          Tunneling              Eschar               Slough

 

PSYCHOSOCIAL
Behavior Cooperative     Uncooperative

Transition to Professional Nursing- Care Plan

Pleasant           Withdrawn            Combative         Other_______________

Language spoken English = speaks and understands         other_________________   Interpreter

 

Part II:  History and Physical
Nursing Care Plan:  Date:                                                        
A.  Client identifiers:

Physician (s):

Age:                        Gender:              Ht:               Wt.               Code Status:

Isolation Status:

 

 

Health States
Date of admission:

Activity level:                                                                Diet:

Fall risk:

 

Client’s chief complaint:

 

Client’s past medical and surgical history

 

 

 

 

Allergies:

 

 

 

Mobility needs: (Independent, partially-dependent, full-assist). Transition to Professional Nursing- Care Plan

 

 

 

Interdisciplinary Consults (PT/OT/RT/ST/other):

 

 

 

Referrals to Specialists (pulmonary, cardiac, neuro, etc.)

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Socio-cultural Orientation
Cultural and Ethnic Background; Transition to Professional Nursing- Care Plan

 

Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, and

financial abuse)

 

Barriers to independent living

 

NSG125 Transition to Professional Nursing- Care Plan

Part III. Medications
List medications, dosages, classifications, and the rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication.  A maximum of twelve (12) medications focus on the medication corresponding to the patient’s primary and chronic health conditions. Transition to Professional Nursing- Care Plan
ALLERGIES:
Medication, Classification, Mechanism of Action  

Dosage/Route

 

Contraindications, Adverse Reactions/Side Effects, Risk Factors,

 

Client Education and Nursing Implications

 

Why is this client getting this medication?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IV: Diagnostic studies and Interpretation (Maximum of 5 lab values)
Labs Normal Values Results What do these results indicate? Identify 2 interventions based on the laboratory findings (examples: Medications, procedures, positioning)

 

Assessment Explanation
 

Identify three (3) nursing interventions based on the Physical Assessment findings

1.
2.
3.
 

State the educational needs of this client.

1.
2.
3.

NSG125 Transition to Professional Nursing- Care Plan

PART V: Clinical Judgement Measurement Model Table

Recognize Cues

Identify five (5) abnormal Signs, symptoms, risk factors, labs, and health history, clinical manifestations.

Prioritize

Using the Recognize Cues column to prioritize the chief complaints. Transition to Professional Nursing- Care Plan

Generate Solutions

List three (3) nursing interventions needed for this client. Use the three (3) interventions identified above.

Evaluate Outcomes

How would you determine the effectiveness of your nursing interventions?

 

1.

 

2.

 

3.

 

4.

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

2.

 

3.

 

4.

 

5.

 

1.

 

2.

 

3.

 

1.

 

2.

 

3.

NSG125 Transition to Professional Nursing- Care Plan

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