What This Document Is
This is a second care plan completed by a nursing student, Kristy Hernandez, for a 38-year-old Hispanic female patient (initials A.R.) at Miami Dade College’s American Medical Academy School of Nursing. It’s a data collection and assessment form used to develop a comprehensive plan of care for a patient presenting with a wound infection, hyperthermia, and hypertension.
Why This Document Matters
This care plan is a core assignment for students in the Fundamentals of Nursing (NUR 1025) course. It demonstrates the student’s ability to gather patient information, identify potential health problems, and begin to formulate a nursing care approach. It’s used as part of clinical skills development and evaluation.
Common Limitations or Challenges
This document represents a *snapshot* of a patient assessment and initial care planning. It does not include the full, evolving care plan with interventions, evaluations, or revisions based on patient response. It is a student work product and should not be used for actual patient care.
What This Document Provides
The document includes: patient demographics, medical history, current diagnoses with brief pathophysiology explanations, vital signs, a focused physical assessment (neurological, cardiovascular, respiratory, and gastrointestinal), and preliminary data related to the patient’s chief complaint of pain and swelling from a recent laceration. It *does not* include a complete nursing diagnosis list, specific interventions, or an evaluation of outcomes. This preview only shows the initial data collection portion of the care plan.