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 to this Hypertension and Type II Diabetes. Chronic
non-healing wound? 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 100000848649392 from CourseHero.com on 08-05-2022 04:46:03 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 collected? Measurement of the wound, culture 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 100000848649392 from CourseHero.com on 08-05-2022 04:46:03 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
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 to this Hypertension and Type II Diabetes. Chronic
non-healing wound? 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 100000848649392 from CourseHero.com on 08-05-2022 04:46:03 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 collected? Measurement of the wound, culture 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 100000848649392 from CourseHero.com on 08-05-2022 04:46:03 GMT -05:00
https://www.coursehero.com/file/53233353/Mrs-Robinson-Care-Plan-Template-and-Rubricdocx/
