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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 | | |...