ARE
QueenBee2
3 years ago
20
files (2)Fullpoint.pdf
ARE.docx
Fullpoint.pdf
Patient Data for NR226 RUA Patient:
Patient History:
Ben Smith is a 75-year-old retired farmer from Southern Illinois. He is widowed and has 3 adult children who live out of state. He is in an LTC for rehab following hospitalization. He has a 60-year history of smoking 2 PPD of cigarettes. He fell 3 months prior to his hospitalization but did not sustain any injuries.
He was admitted to the hospital for an acute exacerbation of COPD. He also has a history of COVID in 2020, HTN, and anxiety.
Medications:
• Acetaminophen 325mg PO Q6 hours PRN • Albuterol inhaler, 2 puffs once daily • Ipratropium bromide nebulizer Q8 hours PRN • Lorazepam 5mg PO Q12 hours • Nicotine patch, change every 72 hours • Prednisone 30mg PO BID • Multivitamin daily
Labs:
• Sputum culture and sensitivity- results showed no infection • UA/UC- WNL • CMP- WNL, except for potassium of 3.4 mEq/L • CBC- WNL, except for platelets of 140k/mL
Imaging:
• Chest x-ray: shows focal consolidation in right lower lobe, suggestive of pneumonia • Hyperinflation of lungs with flattened diaphragm consistent with long-standing COPD • EKG: normal sinus rhythm with rate of 90 bpm
Assessment Data:
• Please be sure to fill in each system, including normal findings • I will allow you to “make up” data that you would think would be abnormal in a patient like this, think of
findings especially in the following systems: o Respiratory, cardiac, musculoskeletal, neuro
• Vital signs: o Temp: 100.6 F, PO o RR: 22 breaths/min, shallow o HR: 90 bpm, regular o BP: 145/90 o O2: 91% on 2L NC o Pain: 7/10, intermittent, chest and upper back
Miscellaneous:
• The patient states that he hates hospitals and doesn’t belong in a nursing home. He says he needs to get back to his farm
• He is impulsive and has tried to get out of bed numerous times, even though he is a stand by assist with a history of falls
• He is non-compliant with medications and has felt nauseated. He does not want to take any meds and “does not need that dang breathing thingy- it’s stupid!” (The nebulizer)
• He states he “will not quit smoking, I’ve been smoking since I was 15 and it hasn’t killed me yet!”
ARE.docx
Nursing diagnosis are
1. Impaired gas exchange related to ventilation-perfusion inequality as evidenced by decreased oxygen (91% on 2L NC).
2. Risk for bleeding as evidenced by decreased platelet count
3. Readiness for enhanced therapeutic management as evidenced by social support services
1st Diagnosis: Actual Problem/High Priority
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Nursing Diagnostic Statement:
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Planning: Short and Long-Term SMART Goals |
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Short-Term SMART Goal:
Long-Term SMART Goal:
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Rationale for Selecting Goal:
Rationale for Selecting Goal: |
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Interventions |
Evaluation of Expected Outcomes |
Evidence to Support |
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Three Interventions for Short-Term Goals: 1.
2.
3.
Three Interventions for Long-Term Goals: 1.
2.
3.
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(Determine and describe if goals/outcomes were met) |
1. Evidence to support evaluation
2. What changes, if any, are needed to promote expected outcomes in the future?
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2nd Diagnosis: Actual Problem/Lesser Priority
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Nursing Diagnostic Statement:
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Planning: Short and Long-Term SMART Goals |
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Short-Term SMART Goal:
Long-Term SMART Goal:
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Rationale for Selecting Goal:
Rationale for Selecting Goal: |
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Interventions |
Evaluation of Expected Outcomes |
Evidence to Support |
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Three Interventions for Short-Term Goals: 1.
2.
3.
Three Interventions for Long-Term Goals: 1.
2.
3.
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(Determine and describe if goals/outcomes were met) |
3. Evidence to support evaluation
4. What changes, if any, are needed to promote expected outcomes in the future?
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3rd Diagnosis: Psychosocial Problem/Need
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Nursing Diagnostic Statement:
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Planning: Short and Long-Term SMART Goals |
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Short-Term SMART Goal:
Long-Term SMART Goal:
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Rationale for Selecting Goal:
Rationale for Selecting Goal: |
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Interventions |
Evaluation of Expected Outcomes |
Evidence to Support |
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Three Interventions for Short-Term Goals: 1.
2.
3.
Three Interventions for Long-Term Goals: 1.
2.
3.
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(Determine and describe if goals/outcomes were met) |
5. Evidence to support evaluation
6. What changes, if any, are needed to promote expected outcomes in the future?
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Linkages Within and Between Diagnoses
Provide a short summary rationale for why these diagnoses were chosen and how they connect to the patient.
Safety-Communication-Infection Control
Safety
Communication
Infection Control
References
Start the references list on a new page. The word "References" (or "Reference," if there is only one source), should appear bolded and centered at the top of the page. Reference entries should follow in alphabetical order. There should be a reference entry for every source cited in the text.
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