Develop a care plan for this patient You are the nurse caring for an older adult, 85 years old, complaining of shortness of breath without any activity. The resident stated, hel
See the scenario attached and complete the care plan form template as much as possible.
SCENARIO
Develop a care plan for this patient.
You are the nurse caring for an older adult, 85 years old, complaining of shortness of breath without any activity. The resident stated, “help, I cannot breathe.” She has no history of any allergies. She is a widow and practices the catholic faith. She has an advance directive do not resuscitate. Medical records indicated patient has diagnoses for chronic failure with hypoxia, peripheral vascular disease, atrial fibrillation, chronic obstructive pulmonary disease, essential hypertension, chronic kidney disease stage 3, gastro-esophageal reflux disease without esophagitis, anemia, hypomagnesemia, type 2 diabetes mellitus without complication, heart failure, pure hypercholesterolemia, abdominal aortic aneurysm with rupture.
On the day of admission, her vital signs are as follows. Alert and oriented times 2, edema plus + 2 skin integrity extremities are cold.
Bp 166/100, HR 105, R 22 Temp 96.7*, Spo2 88 %, pain level 6/10
Weight 184lbs height 68 inches BMI 26.6. Mobility: short distance with rollator walker.
Home medications
Acetaminophen oral cap 325mg tab po q 4 hours for pain.
Diltiazem hcl er extended-release 240mg.
Fish oil 1000mg cap po q daily
Furosemide 20mg tab po q daily
Losartan potassium 50mg po q daily
Magnesium oxide 250mg Tb po q daily
Metformin 1000mg tab po q bid AM and EVENING.
Metoprolol succinate 50mg tab po q daily
Omeprazole 20mg po q daily
Potassium chloride 20meq tab po q daily
Simvastatin oral 40mg tab po daily at bedtime
Name: Date:
Care Plan #
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Nursing Care Plan- Basic Conditioning Factors |
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Patient identifiers: Age: Gender: Ht: Wt. Code Status: Isolation: |
Development Stage (Erikson): Give the stage and rationale for your evaluation |
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Health Status |
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Date of admission: Activity level: Diet: Fall risk (indicate reason): Client’s description of health status: Allergies: (include type of reaction) |
Reason for admission: Past medical history that relates to admission: |
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Socio-cultural Orientation |
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Religious, Cultural and Ethnic background with current practices: Socialization: Family system (support system): Spiritual: Occupation (across the lifespan): Patterns of living (define past and current): |
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Barriers to independent living: |
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ALLERGIES: |
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Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following: 1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication? Medication Classification Dosage & Route Rationale Possible Negative Outcomes |
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CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies). What symptoms does your client present with?
Complications
Treatment (Medical, medications, intervention and supportive)
Risk Factors (chemical, environmental, psychological, physiological, and genetic)
Nursing Diagnosis
Problem statement (NANDA diagnosis):
Related to (What is happening in the body to cause the issue?):
As evidenced by (Specific symptoms):
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LAB VALUES AND INTERPRETETION |
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LAB |
Range |
Value |
Value |
MEANING (If WDL then explain the possible reason for the lab) |
LAB |
Range |
Value |
Value |
MEANING |
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HEMATOLOGY |
CHEMISTRY |
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CBC |
Glucose |
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WBC |
BUN |
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RBC |
Cr |
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HGB |
GFR |
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HCT |
Na |
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PLATLETS |
K |
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Diff: |
CO2 |
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Polys |
Ca |
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Bands |
Phos |
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Lymph |
Amylase |
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Mono |
Lipase |
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Eosin |
Uric Acid |
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GBC indices |
Protein |
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MCV |
Albumin |
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MCH |
Cl |
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MCHC |
Enzymes |
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COAGs |
LDH |
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PT |
