CREATE A CARE PLAN BASED ON THE CLINICAL PATIENT YOU CHOOSE WITH TWO MEDICAL DIAGNOSIS AND TWO NURSING DIAGNOSIS. ONE GOAL FOR EACH DIAGNOSIS. FOUR INTERVENTION AND RATIONAL FOR EACH DIAGNOSIS. BE SURE TO USE THE TEMPLATE ATTACHED.
CHIEF COMPLAINT: Fever and Problems breathing
HISTORY OF PRESENT ILLNESS
This is a 67 year old female with history of right MCA territory infarct with resultant left hemiparesis and aphasia, Type 2 diabetes mellitus, hyperlipidemia and anemia, who was sent to Regency Care Nursing Home on 02/23/17 for a temperature of 100.5 degrees and hypoxia of 85%. She is currently staying at this facility for long term care.
PAST MEDICAL HISTORY: Right CVA with Left Hemiparesis and Aphasia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia.
FAMILY MEDICAL HISTORY: CABG, Coronary Artery Disease and Cancer
SOCIAL HISTORY: no alcohol, drugs or illicit drug use
PATIENT MEDICATIONS AND ALLERGIES
–Atorvastatin calcium tab 80 mg: give 1tab at bedtime for HLD
–Lantus Solution 100unit/ml: inject 20 units subcutaneously at bedtime for diabetes.
–Florastor Capsule 250 mg: give 1 capsule via PEG-Tube one time a day for probiotic.
–Gabapentin Solution 250 MG/5ML: give 5ml via PEG-Tube in the evening for nerve pain
–Ipratropium-Albuterol Solution 0.5-2.5 mg/ 3ml: inhale orally every 4hrs as needed for SOB and administer via neb treatment.
–Glucerna 1.5 @45ml/hr for a total volume of 1000ml: to support weight loss.
PATIENT PHYSICAL EXAM
–Vital Signs: Temp: 98.2, Pulse 78, Respirations 18, O2 98% via nasal cannula (4L), pt denied any pain.
–Neuro: alert and oriented times 2 (person and place), left hemiplegia.
–Eyes: pupils are reactive to light and accommodation.
–Mouth and Throat: moist, pink oral mucous membranes, oxygen in place.
–Cardiovascular: s1 and s2 normal, regular rate and rhythm.
–Lungs: normal bilateral breath sounds.
–Abdomen: soft, nontender, nondistended and no rigidity.
–Skin: warm and dry.
–Extremities: no edema noted.
PATIENT MOST RECENT LABS 03/21/17
– HEMOGLOBIN: 39.3
— PLATELET COUNT: 41
PATIENT MOST RECENT DIAGONOSTIC TEST RESULTS
–Abdomen Ultrasound 09/29/16
· Reason: generalized abdominal pain
· Result: hepatomegaly and no other abnormalities
–Chest x-ray exam 11/30/16
· Reason: consistent dry couch
· Result: no active lung or pleural space disease
–Chest x-ray lateral 01/05/17
· Reason: SOB
· Result: right upper and lower lung filled infiltrates consistent with pneumonia.