Mrs. Robinson Care Plan Template and Rubric GNUR 238 Foundations of Nursing
Practice Mrs. Robinson’s Care
Plan Rubric
Casey Devlin
Assignment Template
*Use information from the Patient information packet and the Health History Packet
Present Problem / Chief Compliant:
open sore on right ankle
History of Present Problem:
Patient is a 65 yr old female here with an open wound with purulent
discharge near her right medial malleolus. Patient states she has had
wound for several weeks.
Patient states recently that the skin around the wound is red and painful to
walk on. Patient states she has tried to use butter to heal her wound.
Wound Assessment:
Where is the wound located? Right medial malleolus
What caused the wound? Patient states she hit her foot on a
shovel
What medical conditions can be contributing Hypertension and Type II Diabetes.
to this non-healing wound? Chronic smoker can be contributing
as well.
Does the patient have associated symptoms? Pain with walking. Associated signs-
Revised and updated Fall 2019 AK / NS
This study source was downloaded by 100000848398116 from CourseHero.com on 06-15-2022 03:34:22 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
, GNUR 238 Foundations of Nursing
Practice Mrs. Robinson’s Care
Plan Rubric
Casey Devlin
elevated temp, redness around
site and purulent drainage.
Any other significant data that needs to be Measurement of the wound, culture
collected?
of the wound, pain scale 1-10. Also
additional
questions about fatigue, nausea.
Narrative Note
4–6 succinct/robust sentences including the following information:
• Demographics and Chief Complaint (CC)
• Significant Past Medical/Surgical History
• Significant Psycho/Social Assessment
• Physical assessment related to the chief complaints, and any associated focused
assessments.
Patient is a 65 yr old female here with an open wound on her right medial malleolus that is red,
has purulent discharge and is painful. Patient has a history of Type II diabetes, hypertension and
a fib. Patient states she does not remember to take all over medications. Patient has 10 pack
years, lives alone and seems to have a lack of resources. Patients vitals were elevated;
temperature taken orally, 100.4 degrees F, BP taken on left branchial, 150/194, HR taken on
right radial, 102 ,RR was 22 and BG was 234.
Revised and updated Fall 2019 AK / NS
This study source was downloaded by 100000848398116 from CourseHero.com on 06-15-2022 03:34:22 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
Practice Mrs. Robinson’s Care
Plan Rubric
Casey Devlin
Assignment Template
*Use information from the Patient information packet and the Health History Packet
Present Problem / Chief Compliant:
open sore on right ankle
History of Present Problem:
Patient is a 65 yr old female here with an open wound with purulent
discharge near her right medial malleolus. Patient states she has had
wound for several weeks.
Patient states recently that the skin around the wound is red and painful to
walk on. Patient states she has tried to use butter to heal her wound.
Wound Assessment:
Where is the wound located? Right medial malleolus
What caused the wound? Patient states she hit her foot on a
shovel
What medical conditions can be contributing Hypertension and Type II Diabetes.
to this non-healing wound? Chronic smoker can be contributing
as well.
Does the patient have associated symptoms? Pain with walking. Associated signs-
Revised and updated Fall 2019 AK / NS
This study source was downloaded by 100000848398116 from CourseHero.com on 06-15-2022 03:34:22 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
, GNUR 238 Foundations of Nursing
Practice Mrs. Robinson’s Care
Plan Rubric
Casey Devlin
elevated temp, redness around
site and purulent drainage.
Any other significant data that needs to be Measurement of the wound, culture
collected?
of the wound, pain scale 1-10. Also
additional
questions about fatigue, nausea.
Narrative Note
4–6 succinct/robust sentences including the following information:
• Demographics and Chief Complaint (CC)
• Significant Past Medical/Surgical History
• Significant Psycho/Social Assessment
• Physical assessment related to the chief complaints, and any associated focused
assessments.
Patient is a 65 yr old female here with an open wound on her right medial malleolus that is red,
has purulent discharge and is painful. Patient has a history of Type II diabetes, hypertension and
a fib. Patient states she does not remember to take all over medications. Patient has 10 pack
years, lives alone and seems to have a lack of resources. Patients vitals were elevated;
temperature taken orally, 100.4 degrees F, BP taken on left branchial, 150/194, HR taken on
right radial, 102 ,RR was 22 and BG was 234.
Revised and updated Fall 2019 AK / NS
This study source was downloaded by 100000848398116 from CourseHero.com on 06-15-2022 03:34:22 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
