Care Plan

You are the nurse caring for an 81-year-old female client in an assisted living facility with a history of dementia, falling,  hypertension, dysphagia, anxiety, insomnia, and depression. The client is regularly feeding with thin liquids. The client has a history of smoking and no other health problems.  

Vital signs: 

• Temperature: 99.2° F 
• Heart rate: 91 beats/min 
• Respirations: 20 breaths/minute 
• O2 saturation: 93% on 2L oxygen via nasal cannula 
• Blood pressure: 110/68 mm Hg  
• Pain: "6/10" 
• Focused assessment findings: 
  
  
  
• Alert and oriented to person and forgetful
• He moves all four extremities, and refuses to ambulate, on a wheelchair
• The apical pulse is regular at 91 beats/minute
• Lungs clear to auscultation, diminished bilaterally 
• Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
• 
  medications
• amlodipine 2.5mg-once a day
• furosemide 20mg-once aday
• atorvastatin 5mg-once a day at bedtime
• melatonin 5mg-once a day at bedtime
• memantine 10mg-twice a day
  
  Using the information from the scenario, create a care plan using the attached template.