Nursing Care Plan

Mrs Allegra Thomas

• Location: Medical ward

• Introduction

• 86yr old female Allegra Thomas was admitted 5 days ago following referral from her GP.

• Situation

• Admitted with electrolyte imbalance, dehydration now improved with IV 0.9% NS over the past few days but

has become increasingly confused again over the last hour.

• Background

• Her daughter Nina took her to the GP after finding her on the floor at home (unwitnessed fall) with

confusion and lethargy. No major injuries noted, small bruise to L) knee. Allegra stated she had been on the

floor for 11 hours, she was dehydrated and blood tests showed hyponatraemia on admission.

• PMH: Hypertension, T2DM, previously high cholesterol, now within normal limits since her husband died, nil

medications for this. NVDx2.

• Drugs: Metformin 1g TDS, Ramipril 5 mg OD (withheld at present)

• Allergies: Bee stings

• Social: Lives alone. Widowed for 3 years. 2 adult daughters, Nina (a retired chemical engineer) lives nearby,

Ella (a seismologist) lives in NZ.

• Assessment/Observations

• A – patent. Talking in complete sentences

• B – RR 21, shallow. Sp02 93% on RA, bilateral equal air entry clear but muffled bases.

• C – HR 121, SR, BP 96/63, CRT 3 secs, cool peripheries, pale

• D – GCS 14 (E4, V4, M6). Confused to time and place, PEARL, Pain 1/10 at L) knee, nil other pain reported.

• E – IVC looks inflamed and red. Painful to touch. Appears a bit shivery. Temp 38.2. Small bruise still visible on

L) knee, nil broken skin.

• F – IVF continue at 80mls/hr. Poor oral intake since admission. FBC shows - +ve balance over last 12 hours.

Urine output 150mls, once over previous 8 hours. Bowels opened yesterday, formed.

• G - BGL 15mmoLs, Ket. 0.0

• Investigations & results

• FBC – WCC 17.3, Hb 117, Platelets 253

• U&E’s – Na 136, K 3.8, Cr 132, HCO3 19.4, Glucose 15.6.

• CXR – minor bibasal atelectasis, improved from admission CXR

• ABG – pH 7.22, PaCO2 40, PaO2 68, HCO3 18, BE –3.2

• Lactate – Lactate 3mmol/L