care plan
Alejo840128
CPLONI.docx
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Student Name: Alejandro Medina |
Date: 10/22/19 |
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Client’s Initials: J.R |
DOB: 01/28/1941 |
Admission Date: 12/09/2018 |
Age:78 |
Sex: M | |
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Religion: N/A |
DNR |
Advanced Directives: |
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Activity: |
Allergies: Seafood, Polen |
Precautions: N/A |
Diet: R |
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Admitting Diagnosis/Chief Complaint: Rehab after car accident ribs fracture and shoulder dislocation , High Blood Pressure |
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Past/Present surgical procedures (dates): N/A |
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Hx. of Present Illness: Pt involve in a car accident during hospitalization contract pneumonia. |
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Meds prior to admission: |
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1. Lasix |
5. Ginseng Caps |
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2. Keflex |
6. |
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3. Pantoprazole |
7. |
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4. Aspirin |
8. |
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Fortis College Nursing Care Plan
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Textbook Picture |
Client Picture |
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Definition: |
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Etiology: |
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Predisposing Factors: |
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Incidence: |
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Pathophysiology: |
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Signs & Symptoms: |
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Diagnostic Tests: |
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Treatment: |
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MEDICATIONS: (TOPICAL, PO, IM, SQ, IV)
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Name/Dose
Route/Frequency |
Safe/Range |
Mechanism of Action |
Indications |
Side Affects |
Nursing Considerations |
Why is client receiving this medication? |
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Lasix |
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Keflex |
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Pantoprazole |
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Aspirin |
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Blood Cell Profile Norm. Values |
Date |
Date |
Date |
Chemistry Profile Norm. Values |
Date |
Date |
Date |
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Hgb 12.0--16.0 |
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Na+ 136--144 |
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Hct 35.0--45.0 |
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K+ 3.6--5.1 |
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WBC 4.0--10.0 |
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Cl 101--111 |
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Platelets 140--350 |
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CO2 22--32 |
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RBC 3.80--5.00 |
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Anion Gap 7--13 |
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MCV 81--100 |
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Glucose 80--126 |
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MCH 28--32 |
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Bun 8--20 |
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MCHC 32.0--36.0 |
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Creatinine 0.7--1.2 |
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RDW 11.5--14.5 |
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Bun/Creat 10--15 |
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MPV 8.8--13.0 |
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Ca++ 8.9--10.3 |
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Neutrophils 40--75 |
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Total Protein 6.1--8.0 |
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Lymphocytes 20--50 |
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Albumin 3.5--4.8 |
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Monocytes 0.0--10.0 |
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Globulin 1.6--3.2 |
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Eosinophils 0.0--5.0 |
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Alb/Glob 1.5--2.5 |
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Abs. Neutrophils |
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Bands |
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Segments |
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Coagulation Norm. Values |
Date |
Date |
Date |
Lipid Profile Norm. Values |
Date |
Date |
Date |
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Ptt 23.2--36.4 sec |
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Total Chol. <200 |
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Pt 11.5--15.0sec |
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Triglycerides <100 |
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INR 2.--3.0 |
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HDL >50 |
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Bleeding Time |
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LDL <100 |
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Cardiac Chem. |
Date |
Date |
Date |
Thyroid Function |
Date |
Date |
Date |
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Total Ck 0--200 |
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TSH (0.34—5.60) |
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Ck MB <7 |
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Myo globulin 8-66 |
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Hepatic |
Date
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Troponin I <0.5 |
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Total Bili. (0.4-2.0) |
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Dir. Bili. (0.1-0.5) |
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Glucose Tol. Test |
Date
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Date |
Date |
Ind. Bili. (0.0-1.2) |
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HGB A1C (3.6-6.8) |
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Alk Phos (38-126) |
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AST (SGOT) (15-41) |
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ALT (SGPT) (14-54) |
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Anemia Eval. |
Date
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Date |
Date |
Amylase (36-128) |
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Arterial Blood Gas |
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Lipase ( 8-57) |
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PH (7.35-7.45) |
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Bile |
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O2 saturation (>90%) |
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PCO2 (35-45) |
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HCO3 (22-26) |
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PO2 (80-100) |
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Urinalysis Norm. Values |
Date
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Date |
Date |
Other Lab Results: |
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Color (straw or amber) |
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Appearance (clear to hazy) |
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Sp.Gravity (1.005-1.025) |
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PH (4.5-8.0) |
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Glucose (Negative) |
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Ketones (Ketones) |
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Other Lab Results: |
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Blood (Negative) |
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Protein (10-140mg/L) |
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Bilirubin |
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Urobilinogen (Negative 0-0.02) |
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Nitrite (Negative) |
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Leucocytes (Negative) |
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Other Lab Results: |
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RBC (0-3/hpf) |
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Casts (0/1pf) |
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WBC (0-4/hpf) |
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Crystals |
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1
1
1
RELATE THE CLINICAL SIGNIFICANCE OF YOUR PATIENTS ABNORMAL LAB VALUES TO THE DISEASE PROCESS YOUR PATIENT IS EXPERIENCING (If any)
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Diagnostic Test & Results
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Date: |
Test Performed |
Location |
Results |
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X-Ray
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MRI
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Scans
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Ultrasounds
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Others
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Date: Patient Assessment
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Mental/ Neuro
Loc pt oriented times 4
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HEENT
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Cardio HR: 80bpm regular BP: 140/100 |
Respiratory RR:21 Lungs Sound heard all lobes crackles on both bases. |
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Peripheral Vas. System: WNP Cap Ref: <3sec |
Abdomen / GI Pt experiencing constipation |
Musculoskeletal/Mobility: Limited ROM due pt Pain |
GU:
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Endocrine: Labs WNP |
Integumentary: WNP |
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Education |
Nursing Diagnosis
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1 Acute Pain Related To physical Injury (fracture ribs) as Evidenced By the pt reports pain, guarding behavior and expressive behavior like restlessness. |
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2 Risk for Ineffective Breathing Pattern risk Factors Include pain musculoskeletal impairment evidenced by signs and symptoms ribs fracture. |
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3 Activity intolerance related to generalized weakness imbalance between oxygen supply and demand as evidenced by pt reports fatigue, feeling weak and dyspnea ECG. |
PLAN OF CARE ASSESSMENT:
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Subjective Data (symptoms) |
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Objective Data (signs): |
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NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
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Short Term: |
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Long Term: |
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PLANNING :
IMPLEMENTATION (NURSING INTERVENTIONS/ACTIONS):
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Date |
Nursing Actions (Assess, Assist, Teach) |
Rationale |
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EVALUATION OF GOALS:
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REFERENCES:
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PLAN OF CARE ASSESSMENT:
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Subjective Data (symptoms) |
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Objective Data (signs): |
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NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
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Short Term: |
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Long Term: |
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PLANNING :
IMPLEMENTATION (NURSING INTERVENTIONS/ACTIONS):
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Date |
Nursing Actions (Assess, Assist, Teach) |
Rationale |
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EVALUATION OF GOALS:
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REFERENCES:
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PLAN OF CARE ASSESSMENT:
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Subjective Data (symptoms) |
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Objective Data (signs): |
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NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
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Short Term: |
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Long Term: |
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PLANNING :
IMPLEMENTATION (NURSING INTERVENTIONS/ACTIONS):
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Date |
Nursing Actions (Assess, Assist, Teach) |
Rationale |
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EVALUATION OF GOALS:
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REFERENCES:
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8
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