Nursing Care Data Collection/Data Clustering/Prioritizing form
Question
Assignment: Nursing Care Plan (Word Processed and APA Format)
Nursing Care Plan Assignment Instructions
Part 1 Care Plan
Case Study:
Paul Johnson is a 60-year-old male who lives alone in 1 bedroom apartment. His wife died 2 years ago and ever since Paul has isolated himself from his friends and is not involved in any social activity. He attends church occasionally which he usually attends weekly. Some days Paul says he “feels lonely” and would like to go out with friends. He has 2 daughters that live out of Province who calls him frequently. He has a history of Parkinson and had a fall 2 days ago. He has a history of Arthritis and states the pain is controlled with Advil. He reports that some days he feels tired and its difficult for him to get out bed. He is unable to ambulates since he had the fall. He is forgetful at times and his been investigated for Dementia. He gets his meals from Meals on Wheels which is delivered to his front door every week. He takes Ensure with each meal. He wants to prepare his own meal but he is afraid of using the stove due to tremors and muscle rigidity from his Parkinson. He has good appetite. He sleeps 6 hours per night and is incontinent of urine and stool because he is unable to get out of bed due to the fall. He does not use sedative to help him sleep. He has an enlarge prostate (BPH) and often feels the urge to void. He has occasional lose stool due to his history of Colitis. Has BM every 2 days. His pulse to lower extremities is normal. His feet and hands are always cold. His abdomen is round and soft with good bowel sound to all 4 quadrants. He has redness to coccyx due to lying in bed in one position with STAGE 2 Pressure ulcer. He has a 10-year history of hypertension and gets dizzy when he gets out of bed. His admission diagnoses are Right Hip Fracture and Headache
History and Assessment
- Admission Date: October 28, 2021. CODE Status: Full Code
- Assessment Date: October 28, 2021
- Religion: Catholic Wife: Deceased
- Social History: Lives by himself in a 1-bedroom apartment, has 2 daughters who live out of town.
- Had a fall 2 days ago and broke his hip. Severe pain 10/10, unable to get out bed, unable to move due to pain, hit his head on a chair. Having dizziness and blur vision after the fall. His right hip is swollen with redness and bruising
- Language: English and French
- Braden Score is 10 and stage 2 pressure ulcer
- Activities of Daily Living: Adam is able to feed himself and needs assistance with bathe He needs assistance to get out of bed since the fall 2 days ago
- He has a history of hypothyroidism, Diabetes, BPH, Parkinson, Hypertension and Colitis. Past surgical history: appendectomy in 1990; Hernia Repair 1993;
- History of MRSA and VRE from previous admission.
- Has a history of back pain that radiates to his leg. States pain Controlled with ADVIL.
- Alert and oriented but is forgetful at times being investigated for Dementia GCS 15
- Wears glasses, no hearing aid
- Gets dizzy when he gets up suddenly from the bed
- Joint pain from osteoarthritis takes Advil. Pain 1/10 at times
- Weakness to arms and legs due to osteoarthritis
- Rigidity and tremor to arms and feet due to Parkinson
- Previously a smoker x6 years but quit smoking over 25 years ago.
- Height is 5 feet 7 inches. Weight 160 pounds. BMI (Calculate)
- His hair looks dull on inspection and not combed.
- Skin pale cool and dry to touch; color pink with bruising to his back and hip, mucous membranes dry as well. Good skin turgor stage 2 pressure ulcer
- Capillary refill to nail beds is <2 seconds
- Patient states he is very sensitive to the cold.
- Medications: Ramipril 10mg PO QD, Levothyroxine 75mcg PO QD, Metformin 1000mg PO BID, Tylenol 100mg PO every 6hours PRN
- Medication Allergic: Penicillin
- Food Allergy: Peanut
- Breathing normal no use of accessory muscle, no nasal flaring, no cyanosis
- Respiratory rate = 18 Spo2= 95% on room air
- BP 135/70, P 78, Temp. 36. Heart Rate 82
- Breath sounds normal no wheezing or crackles, no shortness of breath
- Heart sounds are regular, had an MI in 2020 no complain of chest pain
- Urinary frequency has a history of BPH
- Redness to coccyx with STAGE 2 Pressure Ulcer
- Patient has 1 Ensure with every meal
- Occasional lose stool has a history of Colitis
- Abdomen is round and soft, non-tender with active bowel sounds in all four quadrants.
- Chest X-Ray and CT March. 12
- Blood work completed March 13th results:
- WBC 7.5 Normal (4.5 to 11.0 × 109/L
- Hemoglobin- 120 Normal 120 g/L to 160 g/L.
- Platelet- 200 Normal (130–380 × 109/L)
- Na-Sodium- 135 Normal 136–146 mmol/L
- K+-Potassium- 3.5 Normal 3.5–5.1
- Creatinine- 90 Normal 53 - 115 µmol/L
- Glucose Fasting- 10 Normal 4.0 to 7.0 millimoles/L
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Solution
Nursing Care Data Collection/Data Clustering/Prioritizing form
- Data Collection
- Data Clustering
- Prioritizing
Patient information and assessment data collection
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Date of Admission |
October 28, 2021. |
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Date of Assessment |
October 28, 2021 |
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Gender Identification |
Male |
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Allergies |
Penicillin |
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Code Status |
Full Code |
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Religion |
Catholic wife |
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Admitting Diagnosis |
are Right Hip Fracture and Headache |
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Past Medical History (diagnosis and date of diagnosis if possible)
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He has a history of hypothyroidism, Diabetes, BPH, Parkinson's, Hypertension, and Colitis.
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Past Surgical History (diagnosis and date of diagnosis if possible) |
: appendectomy in 1990; Hernia Repair 1993
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Vital Signs Temp HR BP RR O2Sat on R/A or amount of O2
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36 82 135/70 18 Spo2= 95% on room air |
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Pain O = Onset P = Palliation / Provocation Q = Quality/Quantity R = Radiation / Region S = Associated S&S T = Timing U = Understanding Last Pain Medication? Effect?
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none Pain killers none non The fall he had Whenever he tries to wake up or stands The pain is due to lying in one position None none |
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Sleep & Rest Sleeping patterns (#h/d) Naps Use of sedation Did feeling rest?
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Six hours of sleep each day
Does not use any seductions Yes |
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Mobility Gait, balance Independently ambulatory W/C, Walker, Cane, Crutches Bedridden Level of assistance required for movement (transferring, getting out of bed, walking, eating)
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Balance Independently ambulatory Walker Not Transferring and getting out of bed
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Neurological Level of Consciousness Orientation Mental Status GCS Number Communication Vision Hearing |
Alert oriented but is forgetful at times being investigated for Dementia GCS 15
communicates well Wears glasses No earing aids
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Cardiovascular Radial pulse – rate, rhythm, strength Apical pulse - rate, rhythm Heart valve characteristics Capillary Refill Peripheral Pulses X 4 BP Edema – description, extent, pitting or non-pitting
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He has a 10-year history of hypertension and gets dizzy when he gets out of bed normal function normally Capillary refill to nail beds is <2 seconds Normal BP 135/70
He has a nonpitting |
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Respiratory Respiration - Rate, Rhythm, Depth, Characteristics, Adventitious Sounds Cough (productive or non-productive) Secretions Suction Requirement Oxygen Therapy
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Breath sounds normal, no wheezing or crackles, no shortness of breath No hissing sounds
Productive cough normal none Resettable oxygen saturation Does not need oxygen therapy. |
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Gastrointestinal Abdomen shape, Scars, Lesions Bowel sounds Abdominal palpation BM – last one, usual bowel patterns Bristol bowel movement description Continent/incontinent Height Weight BMI Diet Amount consumed Ability to eat
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The abdominal shape is round and soft good bowel sound In two days
Normal bowel movement convenient 5feet 7 inches 160 pounds 10.53 The patient has 1 Ensure with every meal normal good appetite Normal appetite |
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Genitourinary Continent/incontinent Catheter Condition of Perineal Skin Discharge/odor Urine Assessment – characteristics, amount |
incontinent No catheter
Discharge has no smell incontinent of urine and stool |
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Musculoskeletal Upper body strength Lower body strength ROM Contractures |
Weakness to the arms due to osteoarthritis Weakness to the legs due to osteoarthritis average Normal |
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Integumentary Colour Temperature Skin Hydration Skin Texture Elasticity Skin Turgor Lesions Wounds Scars Braden scale |
color pink normal Pale and less hydrated dry to touch Normal Good skin turgor stage 2 pressure ulcer normal no wounds bruising on his back and hip, mucous membranes dry as well |
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Psycho-social (SELFACNG) S – Self-Esteem: about hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient's self-esteem, sense of self, concerning the world, Sense of meaning and purpose, Value base, Evidence of Emotional Distress, Grief Issues E – Energy Level: Patients with psychological problems often alter the level of activity. L – Lifestyle: Living arrangements, significant relationships, occupation, hobbies, or lack of interest in leisure activities, education, and any other data that provides information about the patient's situation. F – Family System: contact and support from family members or significant others, family stressors, crisis events, and usual coping skills. A – Affect: mood or feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms. C – Culture refers to all cultural, racial, or anthropological variables that influence one's lifestyle and mental health, which may refer to issues of homelessness, religious and spiritual preferences if any. Discuss any related food needs and other areas of impact spirituality will have on their health status. I – Interests: Hobbies and other activities enjoyed N – Needs: As expressed by the patient G – Goals: As expressed by the patient |
The patient has isolated himself from his friends and is not involved in social activities. He has raised the concerns of some days feeling lonely. The fact that he at times forgetful has made him lose his self-esteem and increased the emotional distress wherein the case study states that "Some days Paul says he "feels lonely" and would like to go out with friends." The patient has reported that some days he feels tired, and it is difficult for him to get out of bed. He has been unable to ambulate since he had a fall. He is less active. That is why he is also less social. He wants to prepare his meal, but he is afraid of using the stove due to tremors and muscle rigidity from his Parkinson's. Since his wife has died 2 years ago, Paul has isolated himself from his friends. He is forgetful at times and has been investigated for Dementia. He gets his meals from Meals on Wheels delivered to his front door every week. He sleeps 6 hours per night and is incontinent of urine and stool because he cannot get out of bed due to the fall. He does not use sedatives to He also has two daughters who frequently call him. His wife died two years ago, and he lives alone. He is Unhappy since most of the time, he is forgetful, which has led to him being tested for Dementia. He also has a history of Parkinson's and had a fall 2 days ago.
The patient has shown an enlarged prostate (BPH) and often feels the urge to void and also has a 10-year history of hypertension and gets dizzy when he gets out of bed.
The patient needs immediate care, mostly from the family, to move to live with him. The patient needs to build a more robust social life and engage in more social activities to avoid boredom. |
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Tubes Instruments IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains (IV site, solution, rate)
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Central line
Solutions |
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Safety Falls Risk safety Measures - call bells, bed rails, seatbelts, lap tray Psychological Security Morse Fall Risk |
low Call bells
Therapy The score is 24 |
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List Your 4 top Priorities with Data.
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Priority No. #1
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Priority No. #2
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Priority No. #3
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Priority No. #4
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