I would like a Nursing Care Plan using the clinical case and the school format in the attachment area and using at least 5 references of no more than 10 years old and foll
I would like a Nursing Care Plan using the clinical case and the school format in the attachment area and using at least 5 references of no more than 10 years old and following APA reference guide also included on the attached files
NEW PROFESSIONS TECHNICAL INSTITUTE
4000 West Flagler Street Miami, Florida 33134
(305) 461-2223 / Fax: (305) 461-3029
STUDENT NAME: DATE:
CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES: Advance Directives: Restrains: Y / N DIET (including tube feeding with rate) Admitting Medical Diagnosis:
Chief Complaint:
History of Present illness:
Past Medical History:
Cultural and Spiritual Assessment:
Medications taken at home or before transfer: (include dose and frequency)
Summarize Pathophysiology (in our own words, include definition, etiology and physiology) Definition of Concurrent Diagnoses (all of them)
Correlational of all diagnoses with current condition
Signs and Symptoms: (Indicate which ones your client has)
Diagnostic test for this condition: (Indicate which ones utilized for client)
Treatment (med/surg/pharmacological)
Nursing Interventions and rationale:
Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.
Generic/Trade Name Classification
Major Action Reason Prescribed to Client
Dose Given/Normal Range
Adverse Effects Precautions/Contraindications
Nursing Implication
.
Generic/Trade Name Classification
Major Action Reason Prescribed to Client
Dose Given/ Normal Range
Adverse Effects Precautions/Contraindications
Nursing Implication
Generic/Trade Name Classification
Major Action Reason Prescribed to Client
Dose Given/ Normal Range
Adverse Effects Precautions/Contraindications
Nursing Implication
LABORATORY AND DIAGNOSTIC TESTS
Other Pertinent labs
DATE DIAGNOSTIC STUDY RESULTS SIGNIFICANCE TO PATIENT
NURSING DIAGNOSIS R/T AND EVIDENCED BY- Subjective Supportive Data- Objective Supportive Data
NURSING ACTIONS SCIENTIFIC PRINCIPLE/ RATIONALE
EVALUATION MODIFICATION
NURSING DIAGNOSIS R/T AND EVIDENCED BY- Subjective Supportive Data- Objective Supportive Data
NURSING ACTIONS SCIENTIFIC PRINCIPLE/ RATIONALE
EVALUATION MODIFICATION
DISCHARGE PLANNING
CLIENT’S NEED FOR DISCHARGE INTERVENTIONS RATIONALE
,
7th Edition Reference Guide for Journal Articles, Books, and Edited Book Chapters
Journal Article
Author, A. A., & Author, B. B. (Year). Title of the article.
Name of the Periodical, volume(issue), #–#. https://doi.org/xxxx
Invert names so that the last name comes first, followed by a comma and the initials. Leave a space between initials. Retain the order of authors’ names.
Place the year in parentheses. End with a period.
Capitalize only the first letter of the first word. For a two-part title, capitalize the first word of the second part of the title. Also capitalize proper nouns. Do not italicize. End with a period.
Capitalize all major words in the periodical name. Follow with a comma. Italicize the periodical name (but not the comma after).
Italicize the volume number. Do not put a space between the volume number and the parentheses around the issue number.
Do not italicize the issue number or parentheses. Follow the parentheses with a comma. No issue number? That’s okay. Follow the volume number with a comma.
Include the article page range. Use an en dash; do not put spaces around the en dash. End with a period.
Does the article have a DOI? Include a DOI for all works that have one. Do not put a period after the DOI.
Book Author, A. A., & Author, B. B. (Copyright Year). Title of the book (7th ed.).
Publisher. DOI or URL
Invert names so that the last name comes first, followed by a comma and the initials. Leave a space between initials. Retain the order of authors’ names.
Place the copyright year in parentheses. End with a period.
Capitalize only the first letter of the first word. For a two-part title, capitalize the first word of the second part of the title. Also capitalize proper nouns. Italicize the title. End with a period.
Include the name of the publisher, followed by a period. Do not include the publisher location. Are there multiple publishers? If so, separate them with a semicolon.
Does the book have a DOI? Include a DOI if available. Do not include a URL or database information for works from academic research databases. Include a URL for ebooks from other websites. Do not put a period after the DOI or URL.
Does the book have an edition or volume number? If so, include the number in parentheses after the title but before the period. If both, show edition first and volume second, separated by a comma. Do not put a period between the title and the parenthetical information.
Chapter in an Edited Book
Author, A. A., & Author, B. B. (Copyright Year). Title of the book chapter.
In A. A. Editor & B. B. Editor (Eds.), Title of the book (2nd ed., pp. #–#).
Publisher. DOI or URL
Invert names so that the last name comes first, followed by a comma and the initials. Leave a space between initials. Retain the order of authors’ names.
Place the copyright year in parentheses. End with a period.
Capitalize only the first letter of the first word. For a two-part title, capitalize the first word of the second part of the title. Also capitalize proper nouns. Do not italicize. End with a period.
Write the word “In” and the initials and last name (not inverted) of each editor. Use “(Ed.)” for one editor or “(Eds.)” for multiple editors. End with a comma.
Provide the title of the book in which the chapter appears. Capitalize only the first letter of the first word. For a two-part title, capitalize the first word of the second part of the title. Also capitalize proper nouns. Italicize the book title.
Include the chapter page range. End with a period. Does the book have an edition or volume number? If so, include the number in parentheses before the page range. If both, show edition first and volume second, separated by a comma, before the page range. Do not put a period between the title and the parenthetical information.
Include the name of the publisher followed by a period. Do not include the publisher location. If there are multiple publishers, separate them with a semicolon.
Does the book have a DOI or URL? Include a DOI if available. Do not include a URL or database information for works from academic research databases. Include a URL for ebooks from other websites. Do not put a period after the DOI or URL.
More information on reference variations not shown here (e.g., in-press articles, articles with article numbers, articles without DOIs, books with titled volumes, audiobooks) can be found in the Publication Manual of the American Psychological Association (7th ed.) and in the Concise Guide to APA Style (7th ed.):
Journal articles and other periodicals Section 10.1 Books and reference works Section 10.2 Edited book chapters and entries in reference works Section 10.3
SOURCE: American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000
CREDIT: MELANIE R. FOWLER, FLORIDA SOUTHERN COLLEGE
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Midterm Care Plan
Due on week 5 before midnight on the day of your class. Please make sure you upload the care plan form provided by your school. No excuses allowed.
Mr. Kaplan is a 78-year-old jewish white male, he is a retiree and was admitted to the hospital accompanied by his grandson. He is 100kg at a height of 180cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, the patient complained of shortness of breath for 4 weeks which was worsening on the day of admission and worsening cough. Besides, he also experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea, and leg swelling up to his thigh. Mr. Perez was admitted to the hospital for the same problem 4 months ago.
Mr. Kaplan was diagnosed with heart failure on his last admission and he had also been diagnosed with hypertension for 20 years. Before being admitted to the hospital, the patient was taking Lasix 40mg, Eliquis 5 mg, metoprolol 50 mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. The patient is not allergic to any medication and he does not take any traditional medicines at home. His family history revealed that his father had died of ischemic heart disease 4 years ago while his brother has hypertension. As for his social history, he smoked 2-3 cigarettes a day for 35 years and the calculated smoking pack-years was 5 pack years. Besides, Mr. Kaplan also drinks occasionally.
On examination, Mr. Kaplan was found to be alert and conscious but he was having pedal edema up to his knee. Besides, the patient was noted with bibasal crepitations with no rhonchi. His body temperature was normal. However, his blood pressure was found to be elevated upon admission with a record of 179/100 mmHg with an irregular pulse rate at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while a chest X-ray was conducted and revealed that the patient had cardiomegaly. Lab investigations such as full blood count, liver function test, urea, electrolyte test, and cardiac enzyme were done upon admission. His creatinine concentration was found to be 143µmol/L. Therefore, the calculated creatinine clearance was 68.8ml/min. Besides, there was also blood found in the urine and the echocardiography showed that the patient has sinus tachycardia and EF 45%. In addition, an ECG test was performed on day 1 and the result indicated that there was a T-wave inversion. The patient’s INR was 1.04 which was lower than normal while APTT was found to be slightly higher (59.4 seconds). Mr. Kaplan’s random blood glucose was found to be normal during his hospitalization.
Mr. Kaplan was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient also suffered from hypertension. The management plan included intravenous furosemide 40mg twice daily, Eliquis 5 mg daily, simvastatin 40 mg once at night and ramipril 2.5mg once a day. Besides, the patient was asked to restrict his fluid intake to 500ml per day and oxygen therapy was given to the patient at high flow at 40L/40% using a face mask when the patient was experiencing shortness of breath.
As for his clinical progression, on day 1, the patient complained of shortness of breath, leg swelling, and orthopnea. An echocardiogram showed that he had cardiomegaly. Treatment of CCF was given. Throughout the stay in the hospital, Mr. Kaplan had responded well to the heart failure therapy as there was no more complaint of chest pain or shortness of breath on day 13 and his pedal edema had gradually improved. However, the patient's blood pressure from day 1 to 9 was fluctuating between the range of 102/67-179/100 mmHg therefore, hypertension treatment was given and blood pressure from day 10 onwards had been seen to fall within the normal range. Furthermore, Mr. Kaplan’s renal function became progressively worse from 143µmol/L on admission to 175µmol/L on day 11 and the calculated creatinine clearance on day 11 was 56.2ml/min. Discharge medications same as hospital regimen, O2 2L/m nasal cannula as needed for shortness of breath, follow up with cardiology in 3 weeks and nephrology in 2 weeks. Home with home health services.
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