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RW Care Plan.docx - Miami Dade College – School of Nursing...

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Miami Dade College – School of NursingFundamental of NursingPlan of Patient CareStudent’s Name: __Shadif_Palacios_________________Date: __11/25/20___Time: ____________Client’s Initials: ______RW______Sex: ____M________Admission Date: ____________DOB: _____________Age: ____55 y/o_______Race: _____W_______Admitting Medical Diagnosis (es):Increased Fatigue, thirst and urinationSurgical Procedure (s) (include date):N/AWhat brought you to the institution (Hospital, Home)N/AHistory of Present illness:N/AClient’s understanding of illness:Past medical history:What medications are you currently taking, when/why?
Are your medications causing you any discomfort?
Medications( Topical, PO,IM, SQ,IV):Name/DoseRoute/FrequencySafe/RangeMechanism ofActionIndicationsSide EffectsNursingConsiderationsMedications( Topical, PO,IM, SQ,IV):
Name/DoseRoute/FrequencySafe/RangeMechanism ofActionIndicationsSide EffectsNursingConsiderationsChemistryNormalValueClient’sValueDateCBCNormalValueClient’sValueDate
SodiumRBCPotassiumHGBChlorideHTCCO2MCHCalciumMCVPhosphorusMCHCCholesterolWBCAlbuminNeutrophilsGlucoseBandsBunSegmentsCreatinineEosinophilsMagnesiumBasophilesUric AcidLymphocytesBiliburinMonocytesLipid ProfilePlateletsAmylaseCoagulationLipaseTest(Norms)NormalValueClient’sValueDateLDHPlatelets #HDLPTTLDLPTUrinalysisBleeding Time:ColorINRTurbidityMiscellaneous TestSGTest (Norms)NormalValueClient’sValueDatepHGlucoseKetoneBloodProteinBilrubinUrobilinogenNitrateAbnormal(s)LeukocyteCastRBCCrystalsWBCEpithelial cellBrief Textbook PictureIncludes: Eitiology, Pathophysiology, Signs & Symptoms, Medical Treatments, Prognosis, etc (Compare to Client)TextbookClient
Nursing DiagnosisFatigue related to sleep deprivation evidence by ““I justcan’t seem to get myself going, and always feel like I’m
ready for a nap even if I went to bed early the nightbefore. It really messes with my daytime functioning”Unstable Blood Glucose levels related to fatigue, polyuria,and weight loss evidence by “I’m more tired than usual,that’s for sure.”, “I’m getting up 5 or 6 times a night and

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