Nursing Care Plan

Students Name____Tracy Riddle___________________________________ Dates of Care 09/21/201 !Present _________ P"ysician Dr# $ie%& 'D____________ Pt# Diagnoses ()nclude any Surgical Procedures done since admission*+ Dia%etes mellitus& ,y-ertension& 'ulti-le se%orr"eic .eratosis& Puritis of s.in& Di/erticulosis& 0ladder infection& Cataracts& Peri-"eral /ascular disease& Coronary artery disease& Dorsal .y-"osis& Con1uncti/itis& Consti-ation& 2out& ,y-erli-idemia& )ntermittent /ertigo& C"ronic edema& 3cid reflu4& Dee- /ein t"rom%osis& Pulmonary em%olism& 3ngina# 2ordons 5unctional ,ealt" Patterns ,63$T, P6RC6PT)7N ,ealt" -erce-tion+ Some days I are better than others but most of the time I feel pretty good. It was on a Saturday, last October, I went to get up from my couch and I couldnt get up, I felt so weak and dizzy. I tried se eral times but got scared because I thought I might fall if I did get up. I called !"" and the ambulance came, and they took my blood pressure and it was ##$%"$$. &hey told me that they needed to take me to the hospital. I came here for 'ust for e(tended care, but my son and I decided that it was best for me to continue to li e here because of my high $ife style+ )ursing home* +t states, this is my home now, and I ha e a new roommate, her name is, ,etty. ,ealt" 'aintenance+ ,a%its+ use of alco"ol+ +t. states none 8se of to%acco+ +t. states none 7t"er Recreational or 7TC Drugs+ +t. states none Pre/enti/e ,ealt" 0e"a/iors+ 0reast or testicular self!e4amination+ +t states no Date of last dental e4amination $!%#$"Pro%lems t"at could contri%ute to falls or accidents+ +t reports pain in her lower e(tremities I ha e to use this walker now because of the pain in my legs I ha e some days. 5amily "istory . +t. states none ,63$T, '3N326'6NT 2eneral a--earance+ Race+ /aucasian 2ender+ female 3ge grou-+ elderly 0ody %uild+ a erage Stature+ obese 2rooming+ pt. was clean, clothing was clean, hair short, with natural wa e, fine, grey color. 'ental Status+ widowed Signs of Distress+ none 7/erall "ealt" status+ +t is states pain in her lower e(tremities. +t was admitted permanently to the long term facility after an emergency episode of acute hypertension.

N8TR)T)7N3$ Pre/ious Dietary )nta.e+ Diet* regular, no added salt, 010, soft, low cholesterol, high fiber, low residue, clear li2uids, )+O, list other 9itamins or su--lements+ )ame 5ood Preferences+ 3ist 3--etite* 4 of diet eaten, presence of nausea or omiting, decreased taste sensation. Nutritional )m-airment+ Inability to swallow 5dysphagia6 . none, to solids or li2uids Inability to chew Inability to feed self :eig"t 5luctuations $ast ; mont"s+ )one, lbs. 7ained%3ost Dentures+ 8pper 5partial%full6, 3ower 5partial%full6 8sage . describe

'6T307$)C ,eig"t and :eig"t+ 0ody Tem-erature+ S.in+ Color+ 3ight pink to dark pink or light brown to dark brown, pallor, flushed, cyanotic, ashen, glossy, 'aundiced. Color 9ariations+ 9rythema, ecchymosis%contusion, petechiae, itiligo, pigmented. $esions+ :acule, patch, papule, pla2ue, nodule, tumor, wheal, erruca, ne us, esicle, bulla, pustule, furuncle, erosion, ulcer, fissure, crust, scab, e(coriation, abrasi e laceration, I)/ISIO)S. Te4ture+ Smooth, soft rough thick, scaling Turgor+ ;eturn immediate%return greater than - seconds. Tem-erature and 'oisture+ <arm, dry, e(tremely cool, e(tremely warm, wet, oily. 6dema+ 0bsent%O, or " =, # =, - =, > =. ,air+ Color+ describe $engt"+ describe Te4ture+ ?ine, coarse, pliant, brittle, dull, shiny, lustrous, glossy, resilient, dry, oily. Distri%ution+ thick, thin, e enly distributed, sparse, alopecia, hirsutism Scal-+ Oily, dry, scaling, dandruff, lumps or lesions 5note location, size, tenderness, inflammation or drainage 7ral 'ucous 'em%ranes+ /olor* +ink, pale, cyanotic, reddened. Consistency+ Smooth, moist, dry, bleeding, ulcers, presence of white patches, describe lesions. 2ums+ 1escribe color, te(ture clearly defined margins receding or shrunken, firm, spongy, edematous, any tenderness@ Nails+ Color+ +ink, pale, cyanotic, splinter hemorrhages S"a-e+ ,eaus lines, clubbing, spooned. Te4ture+ Smooth, hard, 'agged, soft Nail%ed+ +ink, pale, inflamed. Ca-illary Refill+ "B# seconds, - seconds or longer. Decu%itus Ris. 5actor+ /alculateC gi e score. Teet"+ 0ny teeth missing upper@ 3ower@ Condition+ loose or brokenC smooth or 'agged edgesC crooked or straightC protrudingC dental cariesC sores. Color+ pearly white and shiny, darkened, brown discoloration Dietary )nta.e+ regular, no added salt, 010, soft, low cholesterol, high fiber, low residue, clear li2uids. )+O, list other 3mount eaten+ D$4 or less E poor D$BFD4 E fair FDB"$$4 E good 5luid )nta.e during care+ 7ral+ gi e in ccs )9+ gi e in ccs

3llergies+ 3ist, )A10 S.in+ ,istory of S.in/,ealing Pro%lems+ none, abnormal healing, rash, dryness, pruritis, e(cess perspiration%diaphoresis 8sual ,ygiene Practices+ ,ath%shower, gi e fre2uency. S.in Care 3ides+ 3ist Tem-erature ranges+

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Pre/ious 8rinary Pattern+ 5re<uency of /oiding+ e ery GG hours or GGG times%day Pro%lems+ +resence of incontinence, dysuria, hematuria, nocturia, urgency, hesitancy Pre/ious 0o=el Pattern+ )umber of ,:s%day, constipation, diarrhea, incontinence, presence of ostomy 8se of la(ati es, enemas, suppositories 3ast bowel mo ement Presence of "ea/y -ers-iration/dia-"oresis

8rinary 'ode+ indwelling catheter, e(ternal catheter, incontinence briefs, ileal conduit, toilet, urinal, bedpan Color+ pale to dark yellow, straw colored, amber C"aracteristics+ clear, cloudy, hazy, sediment, aromatic 0o=el/stool 0o=el Sounds+ audible, hyperacti e, hypoacti e, inaudible, present, acti e, not present e2ually in all 2uadrants 3%dominal a--earance+ Contour+ rounded flat, distended, round, scaphoid, enlarged, protruding, hard, rigid, rela(ed, taut, pendulous, tympanites Symmetry+ symmetrical, asymmetrical Surface motion+ no mo ement, bounding peristalsis, bounding pulsations 5eces+ Color+ dark brown, med. ,rown, mustard yellow green, dark red%bright red, black, tarry, clayBcolored 3mount+ small, med, large Consistency+ soft semisolid, formed, hard, loose C"aracteristics+ mucoid, foulBsmelling, aromatic, pencilBlike, bulky, pasty Drainage+ 3mount+ gi e in ccs, describe size on dressing Color+ pink, red, green, brown, white, yellow 7dor+ aromatic, uni2ue, strong Consistency+ thick, mucoid, watery, thin, frothy, tenacious C"aracteristics* purulent, suppurati e, mucopurulent, sanguineous, blood tinged, serosanguineous, serous

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Pre/ious -attern of acti/ity+ eating%drinking, bathing, dressing%grooming, toileting, bed mobility, transferring, ambulating, stair climbing, shopping, cooking, home maintenance History of tolerance limitations* pain, stiffness, dyspnea, fatigue, fre2uent pauses in acti ity to rest, dizziness 'o%ility aids+ crutches, bedside commode, walker, cane, splint%brace, wheelchair, other $imitations in a%ility+ missing limbs, paralysis deformities, casts 9ital sign ranges+ either since hospitalization or erbal from patient 8se of di ersional acti ities

Present -attern of acti/ity+ eating%drinking, bathing, dressing%grooming, toileting, bed mobility, transferring, ambulating, stair climbing, shopping, cooking, home maintenance. ;ate as independent, use of assisti e de ice, assistance from others, assistance from person and e2uipment, dependent%unable 'usculos.eletal+ Posture+ rela(ed, shoulders back, tense, rigid, slumped, asymmetrical posture, kyphosis, lordosis 'uscle tone+ slight resistance, spasticity, rigidity, flaccidity 'uscle strengt"+ rate all ma'or muscle groups according to the following scale* $E )o muscular contraction "E ,arely flicker of contraction # E 0cti e mo ements with gra ity remo ed - E 0cti e mo ement against gra ity > E 0cti e mo ement against gra ity and some resistance D E 0cti e mo ement against full resistance with no fatigue 2ait+ spastic, hemiparesis, scissors, steppage, sensory ata(ia, cerebellar ata(ia, +arkinsonism 0alance+ steady, unsteady Range of motion+ unlimited, full, limited with crepitation or pain, immobile, decreased, restricted :eig"t %earing+ gi e in percentages, ability to stand on left%right heels%toes, weakness, inability to use either e(tremity Cardiores-iratory+ $ungs+ 0reat" sounds+ clear, crackles, rhonchi, wheeze Rate+ apneic, eupneic, tachypneic, bradypneic R"yt"m+ regular, irregular De-t"+ deep, shallow Coug"+ continuous, persistent, fre2uent, producti e, nonBproducti e, spasmodic, paro(ysmal, tight, loose, deep, dry, hacking, harsh, painful, rasping, e(hausti e 8se of O#* flow rate and method of deli ery . mask, nasal cannula ,eart+ Rate+ gi e in numerical alue, tachycardic, bradycardic R"yt"m+ regular, irregular, regularly irregular, irregularly irregular Peri-"eral 9ascular+ ,+ +eripheral +ulses* strong, e2ual, bounding, thready, imperceptible, weak asymmetrical, absent, "=, #=, -=, >= Sensation+ nontender, can identify light and deep touch, paresthesia, tenderness, pain, tingling, burning, stinging, prickling, numb 'otor+ Hand grasps and foot mo ement* e2ual, strong, weakness, paralysis Present tolerance for acti/ity* pain, stiffness, dyspnea, fatigue, fre2uent pauses in acti ity to rest, dizziness

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Slee- -atterns+ ,edtime, hours slept, Routine+ 0: nap, +: nap, work night shifts, ariable work shifts Slee- aides used+ medication, food, rituals +osition of comfort Pro%lems+ none, early waking, insomnia, nightmares C72N)T)96 @no=ledge $e/el 6ducational le/el ac"ie/ed+ +rimary language spoken 0bility to e(press self erbally <ords or types of e(pressions used 3%ility to follo= /er%al/=ritten instructions+ >esA if no& e4-lain De/elo-mental $e/el+ )nsig"t+ describeC gi e patient statement +ast History of cogniti e%perceptual illness +ast History of sensory perception* Heat Hearing /old Sight &aste &ouch Smell Iertigo Pain 3ssessment+ location, intensity, duration, 2uality, predisposing factors 7rade on "B"$ scale

7%ser/e a--earance+ pale, puffy eyes, dark circles 7%ser/e %e"a/ior+ yawning, dozing, irritability, short attention span

P6RC6PT83$ 'emory 3ong term* intact, impaired, 7II9 9J0:+39 Short term* intact, impaired, 7II9 9J0:+39 S-eec"+ Paralanguage+ 2ualities of speechBpitch, intonation, rate of speaking, oice olume, words that are stressed or accented. 3rticulation+ articulate, not articulate* 19S/;I,9 Se<uencing+ logical, illogical* 19S/;I,9 3--ro-riateness of content+ appropriate, inappropriate Neurological+ 7rientation+ person, place, time Pu-il reaction+ sluggish, brisk, +9;;30 2ras- Strengt"+ $e/el of consciousness+ comatose, unresponsi e to erbal or painful stimuli, semiconscious, stuporous, drowsy, lethargic, alert, responsi e Perce-tual B Cogniti/e+ ,allucination+ absent, present Delusions+ absent, present 3ttention s-an+ intact, not intact* 19S/;I,9 Sensory+ 9isual )m-airment+ absent, present, glasses, contacts, prosthesis 3uditory )m-airment+ absent, present* describe . impaired, deaf, tinnitus 3uditory aide+ absent, present 7t"er sensory im-airments+ absent, present* describe S6$5 C7NC6PT Posture 6ye contact+ present, absent, 19S/;I,9 5acial e4-ression (affect*+ animated, sad, fi(ed, 19S/;I,9 2rooming+ Hair groomed* yes, no Hygiene* good, poor, describe :akeup* present, absent Sha en* yes, no 1ress* neat, not neat* describe 3ffect+ outward e(pressions of feelings or emotions Descri%e+ facial e(pressions 5animated, flat, sad, fi(ed, smiling, frowning, etc.6 0ttitude* 19S/;I,9 64-ressed feelings a%out self+ Self affirmation comments+ present, absent, describe Self derogatory comments+ present, absent, describe 3--ro-riateness of %e"a/ior+ appropriate, inappropriate, describe

S6$5 P6RC6PT)7N De/elo-mental stage of life+ gi e supporting dataKK 3%ility to accom-lis" age le/el tas.s+ describe +resent health goals 3s. t"e -atient+ How would you describe yourself@ <hat do you consider to be your strengths@ <hat do you consider to be your weaknesses@ +atients perception of ability to achie e goals. 0re the goals and responses age related@ 0ody )mage 'ood+ patient describes how he is feeling. 0lso listen for* e(pressions of positi e outlook, e(pressions of negati e outlook. CC 6ric.sons

R7$6 +atterns of relating to others Identification of own role ;esponse to authority, peers, subordinates 0ge, marital status, occupation +erceptions of responsibilities in life, situations at home, work and in the community. 0ny role changes caused by illness C7P)N2 STR6SS /oping patterns, use of counseling, usual methods of problem sol ing Support system ;ecent loss or change in life situation +resence of stressBrelated disorders S6?83$)T> )umber of li ing /hildren, abortions, miscarriages, stillbirths Se(ual selfBfeelings toward se(, role, selfB concept 9ffect of illness or impairment to se(uality +resent se(ual acti ity 8se of birth control 0ge of onset of mensesC menopause 3ast pap smear 5date6 :ammogram 5date6 +rostate e(am 5date6

R6$3T)7NS,)P Obser e patients interactions with others Ierbal, non erbal communication* 19S/;I,9 1oes patient ha e isitors@

T7$6R3NC6 ,eha ior patterns* 0busi e to self or others )er ous, rela(ed, controlled, agitated, mood swingsC describe 0ppearance 0ffect 0bility to reason and make sound decisions* 0ble, unable, describe R6PR7D8CT)96 ,reasts* round, pendulous, saggingC e2ual, pink with%without presence of striae 0reola* pink to dark brown, round, o al, e ened, presence of discharge 7enitalia* presence and distribution of public hair, se(ually mature, isible lesions, odor, drainage Inappropriate se(ual beha ior* 1escribe if obser ed

93$86 Health%illness beliefs Spiritual, cultural, ethnic heritage and pattern of participation in /oncern with meaning of life%death* present, absent, describe /oncern with meaning of suffering* present, absent, describe 0nger towards 7od%religion* present, absent, describe

06$)65 Symbols of ?aith* present, absent, describe /urrent religious%cultural ties* present, absent, describe 5praying, meditation, reading religious artifacts, wearing religious 'ewelry6 Iisits from clergy ,eha ioral patterns of despair* 1escribe any obser ed 5withdrawal, an(iety, grief, apathy, anger, guilt6

,arkauskas, I., StoltenbergB0llen, A., ,aumann, 3. and 1arlingB?isher, /. 5"!!>6 Health and physical assessment. St. 3ouis* :osby. ,ates, ,. 5"!!D6 0 guide to physical e(amination and history taking. 5L th 9d6 +hiladelphia* 3ippincott. /arpenito, 3. 5"!!-6. )ursing diagnosis* 0pplication to clinical practice. 5D th 9d.6 +hiladelphia* 3ippincott. /o(, H., Hinz, :., 3ubno, :., )ewfield, S., ;idenour, )., Slater, :. M Sridaromont, A. 5"!!-6 clinical applications of nursing diagnosis* 0dult, child, womens mental health, gerontic, and home health considerations. 5# nd 9d.6 +hiladephia* ?. 0. 1a is. &aylor, /., 3illis, /., M 3e:one, +. 5"!!-6. ?undamentals of nursing* &he art and science of nursing care. 5# nd 9d.6 +hiladelphia* 3ippincott. <eber, N. 5"!!-. Health assessment. 5#nd 9d6 +hiladelphia* 3ippincott.