Nursing Care Plan- Basic Conditioning Factors|My homework helper
Posted: March 6th, 2023
Name: Date:
Care Plan #
| Nursing Care Plan- Basic Conditioning Factors | |
| Patient identifiers:
Age: 68 Gender: M Ht: Wt. Code Status: DNR Isolation: “N/A” |
Development Stage (Erikson): Give the stage and rationale for your evaluation
|
| Health Status | |
| Date of admission: 08/16/2022
Activity level: Bedbound Diet: Mechanical soft, thin liquid Fall risk (indicate reason): Yes.
Client’s description of health status:
Allergies: (include type of reaction) No known allergies
|
Reason for admission: AMS, PE, UTI, Aspiration PNA
Past medical history that relates to admission: Renal insufficiency, HTN, BPH, DM, Anemia, Vital D deficiency, Unspecified hereditary retinal dystrophy, chronic diastolic (congestive) heart failure, Adjustment disorder with mixed anxiety and depressed mood, anemia unspecified, unspecified dementia, severe, with other behavior disturbance, Type2 diabetics mellitus with hyperglycemia, Hyperlipidemia unspecified, chronic kidney disease stage 3B with heart failure and stage 1, obstructive and reflux uropathy, unspecified hearing lost, unspecified psychosis not due to a substance or known, Visual field defect. |
| Socio-cultural Orientation | |
| Religious, Cultural and Ethnic background with current practices: White
Socialization: Family visit
Family system (support system): Brother
Spiritual: Uknown
Occupation (across the lifespan):
Patterns of living (define past and current):
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| Barriers to independent living:
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| ALLERGIES: | ||||
| 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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| Ferrous sulfate tablet 325mg
|
325mg, one tablet by mouth two times daily
(crush) |
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| Alprazolam
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0.25mg, by mouth every 8 hours as needed | Anxiety | ||
| Zinc Oxide Ointment
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2O% Apply to the sacral area every shift | Skin condition | ||
| Potassium Chloride Packet
|
20MEQ 1packet by mouth in the morning | Hypokalemia | ||
| QUEtiapine Fumarate tablet
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25mg by mouth at bedtime | Psychosis | ||
| Apixaban tablet
|
2.5 mg by mouth two times a day | For DVT prophylaxis | ||
| Omeprazole Capsule
|
40mg 1 capsule by mouth | For GI prophylaxis | ||
| Senna-Docusate Sodium
|
8.6-50mg by mouth at bedtime | For bowel management | ||
| Cholecalciferol
|
1000 unit 2 tablets by mouth one time a day | For vitamin D insufficiency | ||
| Simethicone
|
80 mg 1 tablet by mouth every 4 hours | For gas | ||
| Ondansetron HCI
|
4 mg 1 tablet by mouth every 6 hours PRN | For Nausea and vomiting | ||
| Gabapentin capsule
|
100 mg 1 capsule by mouth three times a day | Traumatic ischemia of muscle | ||
| Acetaminophen
|
325 mg 2 tablets by mouth every 6 hours | For pain management | ||
| MiraLAX powder
|
17 GM/Scoop 1 scoop by mouth one time a day | Bowel management |
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)
SOLUTION
Based on the information provided, the patient has a complex medical history that includes a number of chronic conditions such as renal insufficiency, hypertension, diabetes, anemia, heart failure, hyperlipidemia, and chronic kidney disease. These conditions likely contributed to the patient’s admission for AMS (altered mental status), PE (pulmonary embolism), UTI (urinary tract infection), and Aspiration PNA (pneumonia).
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