Question

FUNDS N101L SUMMER 2017

FUNDAMENTALS SCENARIO for CAREPLAN

PATIENT INFORMATION: Ms. Florence Nightingale, African-American 80 year-old female who is alert and oriented x 4. She presents here to Utopia Hospital via AMR due to an un-witnessed fall at home. She currently lives alone fully independent with her 3 cats. She has two sons (both live out of state) and one daughter who lives two doors down from her mother’s home. She is an active woman who attends church every Sunday, watches her 3 grandchildren every Tuesday and Thursday after school, and plays bridge with the “red hat ladies” on Wednesday evenings at the YMCA. She is widowed as of three years ago and was married for 60 years. She is a retired professor of Nursing and states, “I am enjoying retirement very much – staying active is important to me”. She ambulates with a walker in the house and out.

PATIENT HISTORY: HTN, CHF, Atrial Fibrillation, COPD, GERD, DVT in 2013 for which she was hospitalized at Utopia. She quit smoking 3 years ago. She was a one-pack-a-day smoker for 50 years. She does not consume alcohol or take illicit drugs. Ms. Nightingale is DNR. Patient is allergic to penicillin and cashews.

HISTORY OF PRESENT ILLNESS: Ms. Nightingale has been admitted to Utopia Hospital via AMR for an un-witnessed fall at home. She states, “I tripped over my cat and fell on my left side”. She called her daughter who proceeded to call 9-1-1. Ms. Nightingale states, “I did not lose consciousness”. Vital signs upon arrival to the ER were: BP 130/80, P 116, RR 24, O2 sat 92% room air, T 99 degrees F, Wt 125 pounds, Ht 62”. Lower left lobe crackles on auscultation. She complains of pain 9/10 in her left hip and left thigh. She has a visible bruise measuring approximately 3 x 3” on her lateral left thigh with no skin breakdown or open wound. She presents with bilateral lower extremity edema with 2+ pitting. She states that it is normal for her to have swelling in her ankles. She complains of difficulty urinating and has been getting up at night to urinate. She states that she is “mildly” incontinent and has been wearing pads. She has a 20-guage IV catheter in her right AC infusing 0.9% NS at 25 mls/hr TKO. No signs of redness, edema, or infection.

ORDERS: She has been placed on 2 L O2 NC bringing her oxygen saturation rate to 97%. Patient is NPO for pending surgery. Bed-rest and non-weight-bearing status ordered. Respiratory Therapy order PRN. Morphine 2 mg/ml IVP q2 hours PRN for pain

PATIENT HOME MEDICATIONS:

warfarin 4 mg PO q day, metformin 1000 mg PO q day, furosemide 20 mg PO qday, metoprolol 100 mg

PO qday, ibuprofen 400 mg PO qday PRN, Tums 12+ PO qday PRN

DIAGNOSTICS: 1/1/16, 0800, X-ray findings consistent with left accetabular hip fracture; additionally

full complete fracture of left femur.

Labs: 1/1/16 0900, Glucose Finger Stick = 310, WBC 12,000, HGB 13, HCT 55%, RBC 4.0, PLTS

300,000, NA+ 150, K+ 3.1, CL- 106, BUN 30, CREATININE 1.6, HgbA1c 8.2 %, INR 2.5, PT 12

NOTE TO STUDENTS:

• This is an opportunity to ‘think like a nurse’ – the care plan is a process and a way that we deliver quality healthcare.

• Only one ‘dot com’ reference; the rest should be books (Potter & Perry) and/or nursing journal articles.

• Please do not copy content from above ‘word for word’

• APA formatting to include title page and reference page

• In-text citations

• No Wiki, WebMD, Taber’s, or dictionary

Answer 1

Assessment	nursing diagnosis	planning	implementation	evaluation
Nursing assessment includes mainly two types of data subjective data Pain(9/10) in the leg Objective data Business on the leg history of taking warF daily Increased WBC count	Risk of bleeding and infection after operation related to history of taking warf evidenced by business in the leg without an open wound	collect proper history vital signs and Lab reports of the patient Raise the foot end of the bed to decrease the pedal edema of the patient Provide IP antibiotics to the patient as advised by physician	Proper history of the patient collected vital signs checked and Lab reports are collected in shown to the physician Foot end of the. to decrease the pedal edema that was plus two at the time	Chances of getting infection and bleeding to the patient after infection are decreased