Nursing Care Plan

Nursing Care Plan

Table of Contents
Question 1...................................................................................................................................3
Question 2...................................................................................................................................6
Question 3...................................................................................................................................8
Question 4.................................................................................................................................10
Question 5.................................................................................................................................11
Question 6.................................................................................................................................13
Question 7.................................................................................................................................14
Question 8.................................................................................................................................15
Clinical report documentation................................................................................................17
REFERENCES..............................................................................................................................18

Question 1
Referring to the information provided in Mr McFarlane’s case study, complete the nursing
admission form, on the template provided below, using appropriate medical terminology. Ensure
the documentation meet legal requirements.
NAME: Mr George McFarlane
ADDRESS: 23 Sunset drive, Homerville. 2300
GP: Dr Geoff Waterson
DATE:
AGE ON
ADMISSION: 53
GENDER: Male
ALLERGIES:
PREVIOUS
MEDICAL
HISTORY:
 Patient has Type ll Diabetes which needs close management
 COPD or Chronic Obstructive Airway disease
 Osteoarthritis in the Left Knee
 PVD or Peripheral vascular Disease
LIFESTYLE
PATTERNS:
The occupation of the patient: Long haul truck driver .
Alcohol or ETOH usage is extremely high due to consumption on a
regular basis, High tobacco consumption from smoking. The patient has
high intake of fast food.
ADL
ASSESSMENT:
DIET: 5
MOBILISATION: 3

HYGIENE: 8
ELIMINATION:10
ADMISSION
OBSERVATIONS:
T: 36.9, P: 99, R: 17, BP: 150/100, SpO2: 96%, GCS: 15, Pain score:
8/10
HEIGHT: 170cm WEIGHT:135 kg BMI: 46.7 kg/m2
 2/24 Vital signs
 2/24 Neurological observations
 2/24 neurovascular observations on L) leg
 Non weight bearing on L) Leg
Skin assessment
(Including
Waterlow/ Braden
score)
Special risks
 Neurological deficit: 5 (Type II Diabetes)
 Tissue malnutrition: Smoker: 5 (PVD) + 1 (smoking)
 Major surgery/trauma: 0
 Build/weight for height: 2, Morbidly obese
 Sex and Age: 1, 2 (Male, 53)
 Mobility: 2 (Apathetic)
 Continence: 0 (Complete)
 Visual risk areas/Skin type: 1 (Oedematous)
 Malnutrition screening tool: 0 (no weight loss)
Total score : 19 (High Risk)