Case Study: Mr. Patrick Cowley resident of Shady Acres Continuing Care Centre arrived at Emergency (answered)
Casestudy: Mr. Patrick Cowley resident of Shady Acres Continuing Care Centre arrived at Emergency. He complains of increased cough over the past three weeks and fever for 48 hours. The doctor queries pneumonia and last shift reported an increased temperature and blood work confirms an increased WBC count. Previous nurse gave Tylenol 20 minutes ago for his temperature. Mr. Cowley receives intermittent HDC for hydration. The doctor has started him on corticosteroids. This is also day 3 with no bowel movement and Mr. Cowley requires a bowel routine as ordered by doctor. PATHOLOGY: Dehydration, Pneumonia, Dementia Initial Vital Signs: BP: 145/95 mmHg; Pulse (radial): 100bpm strong/regular; Resp Rate: 20 unlabored/regular; Temp (oral): 38.5 Celsius; SpO2: 92% on RA; Pain rated: 0/10. Post Vital Signs (after all treatment): BP: 135/85 mmHg; Pulse (radial): 85bpm strong/regular; Resp Rate: 18 unlaboured/regular; Temp (oral): 37.5 Celsius; SpO2: 95% on RA; Pain rated 0/10. Fleet enema was effective. NURSING PROCESS ORGANIZATION PLAN FORM - PRIORITY NURSING DIAGNOSIS: CLIENT-CENTRED OUTCOME RELATED TO PRIORITY DIAGNOSIS (Using SMART Criteria): NURSING INTERVENTIONS RELATED TO PRIORITY DIAGNOSIS 1. Identify one intervention related to nursing care. 2. Identify one intervention related to medication administration. 3. Identify one intervention related to teaching. Evaluate effectiveness of the three nursing Interventions: (1. 2. 3.) Medication Research for oral medication ( For Morphine) Medication Name (Generic and Trade name): Purpose: Safe Dose: (show rationale) Nursing Assessment (related to medication) Admission Orders: Vital Signs Routine Methylprednisolone 150mg IM STAT once then doctor to reassess in AM Dulcolax Suppository 10 mg PR if no bowel movement times 3 days Fleet Enema PR one time if suppository ineffective HDC Normal Saline at 50ml per hour. Patient to do 5 repetitions of Deep Breathing and Coughing 3 times a day Monitor Intake and Output every shift Tylenol 325-650mg PO every 4 hours PRN Lorazepam 2-4 mg sublingually at bedtime PRN
Written for
- Institution
- Ball State University
- Course
- Nursing Case study: Patrick Cowley
Document information
- Uploaded on
- April 22, 2021
- Number of pages
- 6
- Written in
- 2020/2021
- Type
- CASE
- Professor(s)
- P
- Grade
- A+
Subjects
-
casestudy mr patrick cowley resident of shady acres continuing care centre arrived at emergency he complains of increased cough over the past three weeks and fever for 48 hours the doctor queri
