206 NCP.docx - ESSEX COUNTY COLLEGE NURSING DEPARTMENT...

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ESSEX COUNTY COLLEGE NURSING DEPARTMENT NURSING ASSESSMENT & PLAN OF CARE CLIENT INITIALS: M.J STUDENT NAME: Osamudiamen Jerry Date:10/24/17 Grade__________ Data Base Name (Pt. Initials): M.J Room: #413 Date of Admission: 10/15/17 Age: 66yrs Date of Birth: 20/24/1951 Place of Birth: New Jersey Sex: Female Marital Status: Single Religion: Christian Occupation: Retired Education: High School Graduate Members of Household Relation to patient Age Name: 3 children sons n/a 14 grandchildren sons and daughters n/a Type of Dwelling/Housing: _______________ Admitting Diagnosis (es) Date of Onset 1. Symptomatic Anemia n/a 2. 3. Current Surgical Interventions Dates 1. 2. 3. Surgical History: History of cardiac surgery, History of mitral valve replacement Medical History: Asthma, OSA – Obstructive sleep apnea, diabetes mellitus, HTN disorder, low hemoglobin, risk for fall, history of mitral valve replacement Psychosocial History: M.J was born in New Jersey and has worked for the internal revenue for 21 years before retirement. She has 3 male children and 14 grandchildren. She help in the upbringing in her grandchildren and inculcate in them the attitude and mindset that will make them navigate these challenging times. As a Christian, my spiritual strength has helped me in times like this. 1
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ESSEX COUNTY COLLEGE NURSING DEPARTMENT NURSING ASSESSMENT & PLAN OF CARE CLIENT INITIALS: M.J STUDENT NAME: Osamudiamen Jerry Revised CC 1/12 Client’s knowledge/perception of illness: Client has a perfect knowledge of health condition as she is able to verbalized
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