Psycho-social Gastro
15 Formal Nursing Care Plan (NCP) – PNUR205 either. Stomach contour is flat, no pulsation noted and nomasses. When auscultating I was able to heal normalbowel sounds. Patient’s abdomen is soft and no pain inthe abdomen. Patient sad that sometimes he isconstipated but at the day of assessment he had bowel movement. Ultrasound results showed that the patient has fatty liver.TMT(P): (Start here) The patient is at risk of getting cirrhosis liver if he won’t stope alcohol intake. That can increase his chances of death. TMT(N): (Start here) I will consult with specialists that can help him to withdraw, and we will find best long term therapy for him. January 2022 Revision Karlos Sun, RN, BScN, MN, CNCC© – PNUR205 Course Lead Sonia Tracey, RN, BScN, MScN – PNUR205 Course Lead
16 Formal Nursing Care Plan (NCP) – PNUR205 Need Assessment Findings (must use properterminologies SUBJECTIVE & OBJECTIVEDATA)(Must use2 SystemsAssessment from your Head to toe) Analysis TMT(P)/TMT(N): Analyze thedata findings using evidence from PNUR126, PATH122, PNUR124,PNUR204, & PATH222. (References must be used) My Priority Need#3Is: Check which category it belongs to below: ☒Activity & Exercise☐Sleep & Rest ☐Sensory ☐Skin & Hygiene ☐Safety ☐Nutrition ☐Urine Elimination ☐Fecal Elimination ☒Oxygen ☐Self-concept ☐Sexuality.Findings (from your head-to-toe assessment): My 1st System Assessment is: (Start here) The patient is a 66-year-old male with more than 40 years of the smoking experience. The patient was diagnosed with COPD, and he is aware that it is essential to change his lifestyle, but the client is not ready to change anything. He is smoking 1 to ½ packs of cigarettes per day. The patient has a productive chronic cough associated with COPD. While at the hospital, the patient is on room air, and his current state doesn't require supplemental oxygen. During my respiratory assessment patient's respiratory rate was 16, and O2 Sat was 97%. These findings are in the normal range, but sometimes the patient experiences difficulty breathing and shortness of breath when performing physical activities. When auscultating his lungs, I noted wheezes bilaterally, but in the right lung, it was much louder. What should be normal for my 1stSystem? (Start here) “Older adults experience anatomical and physiological changes that cause the respiratory system to be less efficient” (Kozier et al., 2018). So the respiratory assessment and further evaluation should priority for the nurse in this case especially if the patient has COPD. Unfortunately, there is no cure for COPD, but treatment and healthy lifestyle can relieve symptoms, improve quality of life, and reduce the risk of death. TMT(P): (Start here) The patient is at risk of developing pneumonia due to chronic disease process and as the worst scenario he is at risk of death.
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