PN2 2571 Care Plan Gray 2.0 {2020} - Rasmussen College

PN2 2571 Care Plan Gray 2.0 {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: 5/21/2019 CLIENT INITIALS: AP ROOM # SP 1 DOB: 3-10-1925 AGE: 94 GENDER: F ADMISSION DATE: 11/15/17 CODE STATUS: DNR ALLERGIES: No HX/ NKA MARITAL STATUS: WIDOW OCCUPATION (FORMER): Teacher/ Hospital volunteer MEDICAL DIAGNOSIS (ES) : Depression, anxiety, hypothyroidism, hypotension ADMITTING CHIEF COMPLAINT : HA and elevated BP, requested by nurse to asses. PAST HISTORY (SURGERY/PROCEDURES) WITH DATES No HX available ORDERS (current orders) RATIONALE (Why is this ordered for this client???) . DIET General/ bed time snack Nutrients and general diet will allow for patient to get all the dietary needs through foods. ACTIVITY N/A I/O N/A VS Vitals per shift Vitals are to be done before giving her BP medicine to determine if she actually needs the dose or if the dose can be held and the doctor should be notified. BLOOD GLUCOSE Sugar taken per MD (Thyroid) Only taken then patient is on a steroid medicine which would be to help with thyroid medication. MD D/C steroid use as of current date. FOLEY N/A NG N/A PEG/PEJ TUBE N/A WOUND CARE N/A RESPIRATORY TREATMENT N/A TRACHEOSTOMY N/A SUCTIONING N/A CHEST TUBE N/A SPECIAL EQUIPMENT Walker Patient uses walker when walking long distances. When pt is in room alone, she can walk self. LAB ORDERS Per MD order When MD prescribes OTHER N/A REHAB SERVICES ACTIVITY OR TREATMENT PLAN & SCHEDULE RATIONALE PHYSICAL THERAPY Discharged from therapy Patient able to walk self / with walker. Therapy no longer needed at this time. SPEECH THERAPY N/A OCCUPATIONAL THERAPY N/A / 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 CT Cervical/Spine 7/15/18 No fracture Patient fall, complaining of pain CT Brain 7/15/18 No hemorrhage Patient fall, complaining of headache from past fall 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?) WBW 3/27/19 7.08 4.08-10.80 RBC 3/27/19 4.25 4.20-5.40 Hemoglobin 3/27/19 13.5 12.0-16.0 Hematocrit 3/27/19 42.9 37.0-47.0 Glucose 3/27/19 173H 70-110 Continue to monitor the glucose closely while contacting the MD. Pt is not diabetic; glucose is high due to getting steroids to help with thyroid disease. If not controlled, MD will prescribe a protocol to abide by. BUN 3/27/19 15 8-28 Creatinine 3/27/19 0.61 1.40-160 Bilirubin 3/27/19 0.33 0.20-1.00 Protein 3/27/19 6.6 5.3-7.3 Albumin 3/27/19 3.8 2.8-5.0 Sodium 3/27/19 137 136-147 Potassium 3/27/19 4.2 3.7-5.1 Chloride 3/27/19 98 97-108