Nursing care plan Health, Medicine, Nursing Case Study (Case Study Sample)
Sample assignment is about the nursing care of patients with two different medical conditions.
source..Clinical Assessment
Clinical assessment is undertaken in clinical environment after gaining consent from the client or their representatives. Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines and followed organizational policies and procedures.
Part – A
You are to conduct a holistic assessment using the health facilities documentation. You will be required to perform the clinical skills:
Clinical assessment
Client 1
Client 2
Body mass Index
Integumentary Assessment
20
Normal
28
Normal
Blood glucose Measurement
150 mg/dl
290mg/dl
Blood pressure Measurement
100/68 mmhg
140/90 mmhg
Oxygen saturation level
99%
98%
Temperature
Pulse
Respiration
99.0 F
62/mt
22/mt
98.6F
86/mt
38/mt
Urinalysis
Color
Appearance
Specific gravity
Protein urine
Glucose urine
Blood urine
Bilirubin urine
RBC urine
WBC urine
PH
Leukocytes Esterase urine
Normal and Less in measure
Straw color
1.010
Negative
Negative
present
Negative
0
10
8.4
Negative
Normal
Straw color
1.017
Negative
Negative
Negative
Negative
0
3
Negative
Mental status Examination
Observation
Appearance
Speech
Eye contact
Motor activity
Mood
Cognition
Orientation impairment
Memory impairment
Attention
Perception
Hallucination
Thoughts
Suicidailly
Homicidally
Delusions
Behavior
Insight
Judgment
Neat
Normal
Normal
Normal
Depressed
None
None
Normal
None
None
None
None
Co-operative
Good
Good
Neat
Normal
Normal
Normal
Irritable
None
None
Normal
None
None
None
None
Co-operative
Good
Good
Neurological observation including reflexes
Open eyes
Verbal response
Motor respons
Spontaneously
Oriented
Normal
Spontaneously
Oriented
Normal
Neurovascular observation
And assessment of peripheral saturation
Color
Temperature
Capillary refill
Swelling
Pulse
Pink
Cold
1 - 2 seconds
No
Normal
Pale
Warm
>2 seconds
Mild
Normal
Pain assessment (including chest pain)
Pain
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