Assignment: Clustering & Prioritizing Data INSTRUCTIONS FOR ASSIGNMENT WINTER 2024 Nursing Care Plan Assignment

Assignment: Clustering & Prioritizing Data INSTRUCTIONS FOR ASSIGNMENT WINTER 2024 Nursing Care Plan Assignment Instructions Assignment # 3 10% Final Grade DUE WEEK 10- MARCH 19 @1159 Case Study: Evelyn Johnson is a 70-year-old female admitted to Noth York General on February 5, 2024 due to a falls and confusion. Admission Diagnosis: Falls & Confusion Medical History: • Hypertension • Diabetes Type 2 • She also has hypothyroidism, Osteoarthritis (AO), Depression. Myocardial Infarction Past Surgical History: Appendectomy in 1990; Hysterectomy in 1993; Lumpectomy 1991 History of MRSA and VRE from previous admission. Code Status: Do not Resuscitate. Height: 185cm Weight: 70Kg Medications: Ramipril 10mg PO daily (history of hypertension) Metoprolol 25mg PO daily (history of MI) Levothyroxine 75mcg PO daily (history of Hypothyroidism Metformin 1000mg PO BID (history of diabetes) Tylenol 100mg PO every 6hours PRN(history of osteoarthritis) Medication Allergic: Penicillin; Sulpha Food Allergy: Peanut Laboratory Investigation: Aic 9%(high) Hemoglobin 116(low) K3.5(normal) Sodium 135(normal) Language: Englis & French On February 6 Her daughter Sophie brought Ms. Johnson to the emergency department due to falls and confusion. She has 3 children and is a widow. Her husband died 5 years ago due to a car accident which Ms. Johnson was driving. Since the accident she has had a lot of guilt and blaming herself for the accident. She was diagnosed with depression but refuses to take medication. She often states, “she is the one who should have died”. One child (Sophie) lives in Manitoba, one son lives in London England and the other son who is the youngest child lives in Atlanta Georgia. Her daughter Sophie is the Power of Attorney (POA). Sophie reports that 2 days ago her mother was asking for her husband who died 5 years ago. She states her mother sounded “funny” asking for her bank card and passport. Sophie states that her mother has had several falls and the last fall one month ago she hit her head and has not been the same since. Her youngest son Paul is insisting that his mother be placed in a nursing home where she can get 24 hours care. On February 7-Assessment Ms. Jonson states she has joint pain 8/10 and is requesting medication for the pain. She states she usually takes Extra strength Tylenol at home. She states that some days the pain is unbearable, she is so weak and tired she cannot get out of bed due to the pain. Her joints are sore and swollen some days, and she is afraid to use them. She has a fear of the pain medication for her arthritis and refuses to take them as she believes that it is causing her to be forgetful. She reports she has lost 5 pounds in 2 months and has no appetite. On occasion she realized that she had been sitting in one position and just staring into space for prolonged periods. Her daughter reports she is much more forgetful and is being investigated for Alzheimer’s disease. February 8-Assessment Ms. Johnson states she tries to ambulate at home to get some exercise and force herself to eat small amount even when she doesn’t feel like eating, and she feels that “it doesn’t worth the effort”. She sleeps 4-6 hours per night and gets up frequently to go to the washroom when her blood sugar is elevated. She notices that her urine is dark when she does not drink water but it has no odour. She states she hates to drink water. February 9-Assessment She has a 10 year history of hypertension and she sometimes feels very dizzy when she gets out of bed. She gets blur vision and dizziness when her blood pressure is high. Her blood pressure today was 145/95. She avoids salty food because she has hypertension. She says she takes blood pressure and heart medications everyday. She also has a history of cataract and unable to drive. She has some bruising to her legs and back from the falls she had and redness to coccyx because she stays in one position when she has pain in her joints. Braden score is 8 which puts her at risk for skin breakdown. Skin pale cool and dry to touch; her mucous membrane in her mouth is dry as well. Capillary refill to nail beds is <2 seconds. She states she is very sensitive to the cold and has a history of hypothyroidism February 10-Assessment Heart sounds are regular, Normal S1 and S2 sound, No jugular vein distention. She states she has been having swelling in her ankle for the past 1 week. She does not have chest pain or heart palpitation. She had an MI in 2004 and takes Metoprolol 25mg daily. Her heart rate today was 75, respiratory rate 20. Breathing normal no use of accessory muscle, no nasal flaring, no cyanosis Spo2= 95% on room air. Breath sounds normal, no wheezing or crackles, no shortness of breath. Previously a smoker x40 years but quit smoking over 10 years ago. February 11-Assessment Ms. Johnson does not know where she is and was informed by the nurse that she is in a hospital. She knows the date and her name. She states her friends have all died and some days she feels lonely. She is not involved in any social activity due to ongoing pain. She is unsteady on her feet and had 4 falls in 4 months. She states her last bowel movement was 2 days ago and she usually have one every day. She takes prune juice at home (1 cup daily) to help with regular bowel movement. Her abdomen is soft, non tender with bowel sound in all 4 quadrants. Her hair is nicely groomed and reports her hair stylist comes to her home every 2 weeks to wash her hair. She states she is not religious and attends church occasionally. February 12 Ms. Johnson was started on Normal Saline at 100m/L per hour to increase fluid intake. A foley catheter was also inserted in her bladder to prevent the frequent getting up at night. A urine sample was sent for culture and sensitivity to determine if she has a urinary tract infection which came back negative. Nursing Care Plan Part 1 Template 10% • Data Collection • Data Clustering • Prioritizing 1. Patient information and assessment data collection Review and collect the assessment data about your client in the case study. Date of Admission Date of Assessment Gender Identification Allergies Code Status Religion Admitting Diagnosis Past Medical History (diagnosis and date of diagnosis if possible) Past Surgical History (diagnosis and date of diagnosis if possible) Medication Dose Route Frequency Reason YOUR patient is taking Vital Signs Temp HR BP RR O2Sat on R/A or amount of O2 Pain O = Onset P = Palliation / Provocation Q = Quality/Quantity R = Radiation / Region S = Associated S&S T = Timing U = Understanding Last Pain Medication? Effect? Sleep & Rest Sleeping patters (#h/d) Naps Use of sedation Feeling rested? Mobility Gait, balance Independently ambulatory W/C, Walker, Cane, Crutches Bed ridden Level of assistance required for movement (transferring, getting out of bed, walking, eating) Neurological Level of Consciousness Orientation Mental Status GCS Number Communication Vision Hearing Cardiovascular Radial pulse – rate, rhythm, strength Apical pulse – rate, rhythm Heart valve characteristics Capillary Refill Peripheral Pulses X 4 BP Edema – description, extent, pitting or non-pitting Respiratory Respirations – Rate, Rhythm, Depth, Characteristics, Adventitious Sounds Cough (productive or non-productive) Secretions Suction Requirement O2 Saturation Oxygen Therapy Gastrointestinal Abdomen shape, Scars, Lesions Bowel sounds Abdominal palpation BM – last one, usual bowel patterns Bristol bowel movement description Continent/incontinent Height Weight BMI Diet Amount consumed Ability to eat Genitourinary Continent/incontinent Catheter Condition of Perineal Skin Discharge/odor Urine Assessment – characteristics, amount Musculoskeletal Upper body strength Lower body strength ROM Contractures Integumentary Colour Temperature Skin Hydration Skin Texture Elasticity Skin Turgor Lesions Wounds Scars Braden scale Psycho-social (SELFACNG) S – Self-Esteem: pertaining to hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient’s self-esteem, Sense of self, in relation to the world, Sense of meaning and purpose, Value base, Evidence of Emotional Distress, Grief Issues E – Energy Level: Patient’s with psychological problems often have an alteration in level of activity. L – Lifestyle: Living arrangements, significant relationships, occupation, hobbies or lack of interest in leisure activities, education, and any other data that provides information about the patient’s personal situation. F – Family System: contact and support from family members or significant others, family stressors, crisis events, and usual coping skills. A – Affect: mood or emotional feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms. C – Culture: refers to all cultural, racial, or anthropological variables that influence one’s lifestyle and mental health, may refer to issues of homelessness, religious and spiritual preferences, if any. Discuss any related food needs and other areas of impact spirituality will have on their health status. I – Interests: Hobbies and other activities enjoyed N – Needs: As expressed by the patient G – Goals: As expressed by the patient Lab Values & Diagnostic Tests Date of lab work Normal value Tubes Insitu IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains (IV site, solution, rate) Safety Falls Risk safety Measures – call bells, bed rails, seatbelts, lap tray Psychological Security Morse Fall Risk List Your 4 top Priorities with Data Priority No. #1 Priority No. #2 Priority No. #3 Priority No. #4

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.