N3715 Nursing Plan of Care – Written Submission Template for Part III of Clinical Assignment
Student: __Abigail McCarron__________________________________
Date: _2024/07/03______________
Clinical Instructor: __Bri______________________
Patient information
Initials: H.M. Helen Manzer Age: 73 Sex, Gender Identity & Female, Heterosexual
sexual orientation:
Ethnicity: Caucasian Citizenship: Canadien (dis)ability: NA
Admitting diagnosis:
Chronic Subdural Hematoma, following fall at home
Pathophysiology:
Subdural hematomas develop within the space between the dural and arachnoid layers of the brain; this is called the subdural space. Chronic
subdural hematomas develop more slowly then acute or subacute hematomas and are more common in elderly population, where age
related changes in the brain allow for more space for fluid to collect. This puts pressure of the brain and causes local inflammation increasing
intercranial pressure. (Patho text, p.356)
N3715 Summer 2024 1
, N3715 Nursing Plan of Care – Written Submission Template for Part III of Clinical Assignment
Interpretation of Assessment- Subjective data
Sources of data Relevant Findings Clinical significance
Health history (including past Hx of falls, HTN, Bipolar Disorder, - Increased risk for infection related to
surgeries or other treatments) T2DM. immunosuppressive effects of type II diabetes.
- Increased risk of injury due to fall history.
Currently post-op left burr hole - Increased risk of blood glucose complications related
evacuation to treat subdural to type II diabetes, such as HHS.
hematoma. - Increased risk for arterial and vascular health
conditions related to diabetes and chronic
hypertension
- Risk for recurring subdural hematoma
- Risk for neurological deficits related to recent brain
injury.
Family health history NA
Current medications - Ozempic 1mg/0.75ml inj subQ - Stimulate pancreas to produce more insulin
weekly - Neuropathic pain, seizures (not for her denies
- Pregabalin 150mg PO q HS seizure history
- Pregabalin 100mg PO q am - Metformin: decreases amount of glucose you absorb
- Metformin 500mg PO BID - Gliclazide: stimulates pancreas for produce more
- Gliclazide 120mg PO daily insulin.
- Perindopril 4 mg PO daily -
- Indapamide 1.25mg PO daily
(check that)
- Rosuvastatin 10mg PO daily
Socio-demographic characteristics: Living in Weymouth, Digby with - Has sufficient medical coverage and support systems
husband. Has Daughter living in intact.
Bedford. Has health benefits to cover
private room.
N3715 Summer 2024 2
Student: __Abigail McCarron__________________________________
Date: _2024/07/03______________
Clinical Instructor: __Bri______________________
Patient information
Initials: H.M. Helen Manzer Age: 73 Sex, Gender Identity & Female, Heterosexual
sexual orientation:
Ethnicity: Caucasian Citizenship: Canadien (dis)ability: NA
Admitting diagnosis:
Chronic Subdural Hematoma, following fall at home
Pathophysiology:
Subdural hematomas develop within the space between the dural and arachnoid layers of the brain; this is called the subdural space. Chronic
subdural hematomas develop more slowly then acute or subacute hematomas and are more common in elderly population, where age
related changes in the brain allow for more space for fluid to collect. This puts pressure of the brain and causes local inflammation increasing
intercranial pressure. (Patho text, p.356)
N3715 Summer 2024 1
, N3715 Nursing Plan of Care – Written Submission Template for Part III of Clinical Assignment
Interpretation of Assessment- Subjective data
Sources of data Relevant Findings Clinical significance
Health history (including past Hx of falls, HTN, Bipolar Disorder, - Increased risk for infection related to
surgeries or other treatments) T2DM. immunosuppressive effects of type II diabetes.
- Increased risk of injury due to fall history.
Currently post-op left burr hole - Increased risk of blood glucose complications related
evacuation to treat subdural to type II diabetes, such as HHS.
hematoma. - Increased risk for arterial and vascular health
conditions related to diabetes and chronic
hypertension
- Risk for recurring subdural hematoma
- Risk for neurological deficits related to recent brain
injury.
Family health history NA
Current medications - Ozempic 1mg/0.75ml inj subQ - Stimulate pancreas to produce more insulin
weekly - Neuropathic pain, seizures (not for her denies
- Pregabalin 150mg PO q HS seizure history
- Pregabalin 100mg PO q am - Metformin: decreases amount of glucose you absorb
- Metformin 500mg PO BID - Gliclazide: stimulates pancreas for produce more
- Gliclazide 120mg PO daily insulin.
- Perindopril 4 mg PO daily -
- Indapamide 1.25mg PO daily
(check that)
- Rosuvastatin 10mg PO daily
Socio-demographic characteristics: Living in Weymouth, Digby with - Has sufficient medical coverage and support systems
husband. Has Daughter living in intact.
Bedford. Has health benefits to cover
private room.
N3715 Summer 2024 2
