What This Document Is
This is a completed Nursing Care Plan (NURS 323) created as a student assignment for California State University San Marcos. It details the assessment, diagnosis, and planned interventions for a 72-year-old male patient admitted to the hospital with acute cholecystitis and mild pneumonia, alongside a complex medical history including atrial fibrillation, COPD, and diabetes.
Why This Document Matters
This care plan is intended for instructors evaluating a student’s ability to apply nursing concepts to a real-world patient case. It demonstrates the student’s skills in patient assessment, problem identification, and the development of a comprehensive plan of care. It’s a key component of the Medical Surgical Care of Adults I course.
Common Limitations or Challenges
This document represents *one* student’s interpretation and application of nursing principles to a specific case. It should not be used as a substitute for independent clinical judgment or comprehensive medical guidance. It is a learning tool, not a definitive treatment protocol.
What This Document Provides
The full care plan includes: patient history (medical, surgical, social), admission assessment findings (vitals, physical exam), identified nursing diagnoses, prioritized interventions with rationales, and a risk assessment related to falls and skin integrity. It also contains documentation of the patient’s intake and output, pain levels, and relevant lab values. This preview does *not* include the full rationale for each intervention, detailed medication administration information beyond what is listed in the patient’s medication list, or a complete evaluation of the plan’s effectiveness.
