PN2 2571 Care Plan 2020 - Rasmussen College

PN2 2571 Care Plan 2020 - Rasmussen College Nursing Clinical Packet Patient Assessment and Care Plan Instructions to student: 1) You must submit a minimum of two acceptable packets to pass your clinical. Each packet is worth 35pts towards your Fundamentals course grade. 2) Please submit the packet electronically in your clinical course shell, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly. PATIENT ASSESSMENT FORM STUDENT NAME: Marina Marmolejo DATE: 2/8/2019 CLIENT INITIALS: JC ROOM # 124 DOB:8/18/34 AGE : 84 GENDER: F ADMISSION DATE: 1/25/15 CODE STATUS: N/A ALLERGIES: N/A MARITAL STATUS: Widow OCCUPATION (FORMER): teacher MEDICAL DIAGNOSIS (ES) Dementia ADMITTING CHIEF COMPLAINT : forgetfulness PAST HISTORY (SURGERY/PROCEDURES) WITH DATES N/A ORDERS (current orders) RATIONALE (Why is this ordered for this client???) EXAMPLE: DIET 2 g Sodium diet with nectar thick liquids only Sodium is restricted due to edema in the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke. DIET regluar No difficulty swallowing ACTIVITY Mobile No need for assistive devices I/O Q8 Check output once per shift VS Q8 Check vitals once per shift BLOOD GLUCOSE daily General monitoring FOLEY N/A NG N/A PEG/PEJ TUBE N/A WOUND CARE N/A RESPIRATORY TREATMENT Breathing treatments BID Shortness of breath TRACHEOSTOMY N/A SUCTIONING N/A CHEST TUBE N/A SPECIAL EQUIPMENT N/A LAB ORDERS UA, CBC To monitor increasing confusion OTHER REHAB SERVICES ACTIVITY OR TREATMENT PLAN & SCHEDULE RATIONALE PHYSICAL THERAPY daily Increase activity SPEECH THERAPY N/A OCCUPATIONAL THERAPY daily Increase ADL`s / 1 pts IVs (if applicable) IV FLUID AND RATE: N/A SITE LOCATION AND CONDITION: N/A LAST DRESSING CHANGE: N/A LAST TUBING CHANGE: N/A GAUGE: N/A REASON FOR IV ACCESS: N/A DIAGNOSTIC TESTS: (at least 2) DATE RESULTS REASON FOR TESTING AND IMPLICATIONS FOR NURSING CARE Mini Cognitive test 1/13/17 Positive Patient expressed confusion and orientation CT of brain 12/30/18 Positive confusion, frequent falls, eloping LAB TEST (fill in each line- 13 lines) DATE RESULTS NORMS REFERENCE RANGES IMPLICATIONS FOR NURSING CARE (WHAT CAN YOU DO TO HELP IMPROVE AN ABNORMAL RESULT?) UA 1/13/17 Positive Negative leukocytes Good peri care, frequent toileting Amnonia 12/3/18 Negative 15-45 U-DL Administer lactolose Lactic acid 2/5/12 Negative 2 Administer antibiotics, IV fluid Procalcitonin 12/3/17 Negative .15 NG per ML Administer antibiotics, IV fluid Blood cultures 1/3/17 Negative Negative Administer anitbiotcs, repeat blood cultures within 24 hours. Sodium 12/3/18 137 135-145 IV fluid, incread/decrease salt intake Potassium 1/12/17 4.0 3.5-5 Kayexalate to lower potassium- supplements to rise.