What This Document Is
This is a RAM (Rapid Assessment Model) Care Plan for Edith Jacobson, a patient at Jersey College Nursing School’s clinical site. It represents a focused nursing assessment completed by a student nurse, SiAsia Vaughn, on October 1st, 2021. The care plan centers around Ms. Jacobson’s primary diagnosis of a left hip fracture and associated risk factors, including a history of osteoporosis and recent reports of dizziness. It’s a snapshot of her condition upon admission, designed to inform immediate nursing care.
Why This Document Matters
This type of document is crucial for LPN to RN transition students. It demonstrates the application of assessment skills, prioritization of nursing diagnoses, and the development of a preliminary care plan. Practicing nurses will find it valuable as an example of focused assessment documentation and a starting point for understanding a patient’s needs following a hip fracture. It’s used during clinical rotations to guide patient care and is evaluated by instructors to assess student competency.
Common Limitations or Challenges
This RAM Care Plan is a *partial* assessment, completed at a single point in time. It does not represent a comprehensive medical history or a complete, finalized care plan. It’s a dynamic document, meaning it’s intended to be updated as Ms. Jacobson’s condition changes and more information becomes available. It also doesn’t include the full rationale behind nursing diagnoses or detailed interventions beyond initial considerations.
What This Document Provides
This preview offers a view of the following key elements included in the full document:
* Patient demographics and code status.
* Vital signs and a focused physical assessment (cardiovascular, respiratory, neurological, skin).
* Medication administration records (Enoxaparin, IDocusate, Morphine).
* Laboratory results (CBC, HTC, WBC, Platelets, ECG findings).
* Initial nursing diagnoses based on observed behaviors and stimuli.
* A brief psychosocial assessment, including support systems and potential alterations to body image.
* Patient education points related to fall prevention, positioning, and ADL assistance.
This preview *does not* include the full, prioritized list of nursing diagnoses, detailed care plan interventions, or the student’s reflective analysis of the assessment process.
