care plan 2

Client Code Name: D L

Client's Age: os Gender: F

Present Medical Diagnoses: AFIB, HTN, hypothyroidism, chest Pressure

Present Surgery (if applicable): NO 

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

Spiritual Well-Being:

Allergies: Alleres tetracy _____ Augmentin Code Status:

Vital Signs: T & 8 P 89. R 15 BP 120/80

SPO₂ A

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Fall Risk Assessment (include score): Pain assessment (include reassessment):

Time : 8am

Score : 

Intervention : 

Reassessment Time : 11am

Score : 0

Diagnostic Assessments-Important EKGs, X-Rays, and Labs

Lab/Other Test : WBC, RBC, HG?, HCF, PLATELET, MONOCYTE

Patient values : 5-2, 2-52, 39-6, 87-2, 186, 7-2

Inference

Medications Ordered for Client:

Medication and Dose with : Aspirin, Famotidin, nebivolol, enoxaparin 

Generic Name of Drug : 81m, 40mg, 10mg, 100mg

Brand name : 9

Times of Administration

Indications of Drug

Adverse Effects

Nursing Implications

Treatments and Procedures : Pti Enoxaparin

Day & Times : 1 a day

Rationale : to treat blood clots

Nursing Interventions:

Assessment Findings : R

Diagnoses

Expected Outcomes

Nursing Interventions

Evaluation

Reflections of the day: