Case Study

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Chamberlain College of Nursing

Nursing 324 - 325 Care plan Packet

Date of care:_____8/15/2013__________ Client Initials:_DC__ Sex:___F_ Age:_49__ Rm#__302A___

Religion:__Babtist____ Allergies:___Dust, Morphine, Z-Pak, Erythromycin, Levofloxacin. Admission date:_8/7/2013___ Code status___FULL____

Admitting diagnosis _______E. coli Infection of abdominal wound___

Social Hx:______

PMH: Plasma Cell Myeloma, Left Breast Cancer, Mastectomy___________________________

Recent Surgeries ___Breast Reconstruction 7/16/2013___Stem Cell Transplant 7/2011______

Chief Complaint _____Wound that will not heal

Narrative Note/SBAR:

_________Aleart and Oriented x 3________________________________________________________________ ________Shower Independently in A.M between wound dressing change _______________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Psychosocial Assessment: ___

Calm; Cooperative. ____________________________________________

__________________________________________________________________________________________________

DIAGNOSTIC TESTS

|Test |Date |Result |Reason(s) Needed and if abnormal- why? |

|CXR | | | |

|EKG | | | |

|CT | | |...