An-Najah National University ‫جـامعـة الـنـجــاح الـوطـنـيـة‬

Faculty of Medicine and Health Sciences ‫كـلـيـة الـطـب وعـلـوم الـصـحـة‬

Department of Nursing and Midwifery ‫دائـرة الـتـمـريـض والـقـبـالـة‬
Nursing care plan for adult health (2)
Student's name: ‫أمين‬ University number:
Date: 4/4/2018 Wednesday Ward:
Instructor name: ‫ فادي‬.‫أ‬
Demographic Data: "5 points"
Client initial : Bed No: 6-1
Age: 39 years old Sex: Male
Marital status: Married Date of admission:04/04/2018
Diet: Regular diet
IV Fluids:
- Type of IV Fluid:
- Amount: /24 hrs
- Rate: ml/hr

Vital signs:
-Pulse: 78 beats/min –Temperature: 36.8 C ax
-Blood pressure: 126/73 mm Hg – Respiratory rate:18 breaths/min
-SpO2: There is no device to measure SpO2.

Pain:
- Pain Assessment Tool:
- Pain Score:
- Pain Management:
Medical diagnosis:

1
Laboratory Dataand Major Diagnostic Tests: "5 points"
- Laboratory Data
1. Clinical chemistry:
Date Test name Patient level Normal value Meaning of abnormal
13/02/2018 Creatinine 0.78 0.7-1.2 mg/dl Normal level
13/02/2018 BUN 17 6-20 mg/dl Normal
2. Haematology:
Date Test name Patient level Normal value Meaning of abnormal
04/04/2018 CBC - WBC 6.6 4.6-11 K/uL Normal level
04/04/2018 CBC – RBC 4.96 4.6-6.1 M/uL Normal level
04/04/2018 CBC - HGB 14.5 13.5-17.5 K/uL Normal level
04/04/2018 CBC - PLT 300 140-450 g/dl Normal level
04/04/2018 CBC - MCV 89.1 80-100 fL Normal level
04/04/2018 ESR 45 0-10 Mm/hr Due to inflammation
04/04/2018 INR 0.97 0.9-1.8 Normal level
04/04/2018 PT 12.7 11-15 sec Normal level
04/04/2018 APTT 28.6 25-35 sec Normal level
3. Serology:
Date Test name Patient level Normal value Meaning of abnormal
13/02/2018 CRP 14 0-5 g/l Due to infection
- Major Diagnostic tests:
Date Test name Result
04/04/2018
04/04/2018

2
Drugs: "5 points"
Medication Frequency Action Rational Adverse Nursing
name Route reactions consideration
Generic & Dose
trade
Cefazolin 1g Interferes with To treat skin and CNS: seizures * Monitor BUN
On call bacterial cell wall soft-tissue CV: Edema and serum
sodium I.V synthesis infections EENT: creatinine for
by inhibiting the Hearing loss early signs of
GI: hepatitis nephrotoxicity.
final step in the
GU: Elevated Also monitor
crosslinking BUN and fluid intake and
(Cefazolin) of peptidoglycan serum output; decreasing
strands. creatinine urine
levels output may
Antibiotic RESP: indicate
Dyspnea nephrotoxicity.

Nursing Care Plan "10 points"

Please discuss 4 Nursing diagnosis in priority
Nursing Care Plan“Put them in priority "