CLINCAL DAY #3/ #4NEW YORK UNIVERSITY COLLEGE OF NURSINGADULT AND ELDER 1 (NURSE-UN.0240)MIDTERM NURSING CARE PLANStudent’s Name:Clinical Unit:Date of Patient Care:Clinical Instructor:Demographic Data:Patient Condition::Age:Gender:Date of Admission:Advance Directives:Allergies/Reaction:DNR/DNI Status:ASSESSMENTSUBJECTIVE DATAReason for Seeking Care (What brought you to this hospital?):Past History:He has had multiple falls over the last two years due to neuropathyMedical (Include date condition was diagnosed, if known):High blood pressureHeart attackStrokeDepressionAnemiaCancerAsthmaDiabetesSeizures5500Linn Aasly GribetzProfessor Barbara Schwartz9/30/21None66(4/6/1955)MaleStable,alert,A&O x49/29/21Full codeBee stings, and some seasonal allergiesFell while out to lunch and could not get up for 4 hours after dueto weakness. Denies any other painYes, diagnosed in2021NoNoYes. Started during his college daysaround 1975NoNoNoNoYes. Had a seizure in 1986but none since
CLINCAL DAY #3/ #4Deep vein thrombosisKidney failureArthritisThyroid diseaseArrhythmiaOthersSurgery/Procedure (Include dates, if known):DateType of Surgery/ProcedureMental Health:Any mental conditions such as depression and anxietyYesAny history of eating disorderNoAny history of taking medications or received treatment for psychiatric conditionYesPsychosocial/Family:ReligionCultural/Ethnic backgroundMarital/Partner statusNoNoNoNoYes. Atrial fibrillationdiagnosed in 2020Neuropathy04/2021Watchman insertion1965TonsillectomyAgnosticNorwegian, Swedish and Irish AmericanSingle, never married
CLINCAL DAY #3/ #4Support system/caregiverLiving arrangementOthers (Tobacco use, Alcohol use, etc.)Review of Systems (Put an X to all that apply):Overall Health StatusGoodFairXPoorNeurological/HEENOTDizzinessNoWeaknessYes, neuropathycomes and goes so heexperiences weakness in hislower extremities at varyingtimesTremorsNoSeizuresYes,Yes. Had one seizure in 1986butnone sinceOrientation (person, place,time, situation) and verbalizes(i.e., A&O x 4).Yes, he isA&O x4Vision lossNoNoneApartment, no roommatesAlcohol use disorder. Started drinking in 1980 thenstopped in 1984 and was sober for 30 years beforestarting to drink 7 years ago again. Drinks about 21cans of beer per week. Smoked about 1 pack ofcigarettes every day for 30 years (30 pack years) butquit around 5 years ago
CLINCAL DAY #3/ #4Double visionNoBlurred VisionNoInspects pupils, stating if they are equal,round, reactive to light andaccommodation (PERRLA).PERRLA andEOMRinging in earsNoDecreased hearingNoOrientation (person, place, time, situation)and verbalizes (i.e., A&O x 4).Yes, he isA&O x4Inspects skin of head and neck andstates if there is any obvious redness,broken skin, rashes, scars, and/orlesions.Skin intact. Slight dryness on his faceInspects mouth forabnormalities and verbalizesfindings (i.e., lesions, missingteeth, dentures, redness ofgums, and/or dry mouth).
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