Formato Para Planes De Cuidados.

NURS-181 Care Plan

Sarah Oakes

Georgetown University
I. Patient information
|Date of admission: |02/25/11 |Admission |Syncope and a fall. She has severe facial bruising, SOB, and Afib with |
| | |diagnosis: |RVR |
|Date cared forpt: |03/01/11 | | |
|Pt’s Initials: |SC |Co-morbid |CHF, COPD, dementia, HTN with orthostatic hypotension, hypothyroidism, |
| | |conditions: |history of falls|
|Age/Gender: |90/ F | | |
|History of present illness: Patient was admitted three days ago after an unwitnessed fall in an assisted living facility. She is healing from a |
|large facial bruise and being observed for syncope, SOB andsymptoms of her Afib. Patient is on the CHF protocol. The night nurse reported she |
|was extremely agitated last night, and she attempted to walk out of the unit several times with her gown undone. She is an elopement risk (green |
|gown). |
|NursingAssessment: Patient is alert and oriented to person, but does not know the place or date. Her demeanor is pleasant and she is cooperative |
|with directions. Vital signs at 0830 are T=95.9, P=79, BP = 139/91, R = 14 on RA, Pulse Ox= n/a (broken), and she reports no pain. She has a large|
|region of blue-yellow ecchymosis on her face from her forehead, around her eyes, to her cheeks, with someswelling. Her vision with glasses |
|appears adequate for ADLs. Patient has difficulty hearing, but no hearing aids. Patient’s breathing is shallow and unlabored. She has crackles and|
|an expiratory wheeze in the LRL and LLL, and had diminished breath sounds bilaterally in the upper lobes. Heart sounds are sinus rhythm. She has |
|normal bowel sounds in all four quadrants and she reports notdifficulty with her bowel movements. The patient has equal peripheral pulses in her |
|upper and lower extremities and no edema. The rest of her skin is clean, dry and intact with good turgor. The patient can ambulate but fatigues |
|within a few minutes while standing. Patient is very thin (49.98 kg/168cm) and has very little muscle mass. BMI calculated is 17.2 |
|Relevant Labs:|
|Lab/Diag.Test |
|Result|
|Normal Range |
|Implications |
||
|WBC |
|14.14 |
|3.5 – 10.8...