Associate Degree in Nursing NURSING CARE PLAN Student Name: Clinical Location: Term: Cohort: Date: ADMISSION DATA Directions: Chart all information correctly; if data wasn't obtained, mark box as 'N/A' instead of leaving it blank. For data with multiple options (indicated by '/'), only include your findings and delete all other options. If there is a '?,' input a value. INITIALS: AGE:68 GENDER:M ADMIT DATE: DATE OF CARE: SPIRITUALITY / RELGION: Christian OCCUPATION: Clerk LANGUAGES SPOKEN · English CODE STATUS Full code . ALLERGIES: NKA LANGUAGE BARRIER · Tracheostomy Other: N/A . · ADVANCED DIRECTIVE: No o POA: N/A . LIVING WILL: No ADMITTING (MEDICAL) DIAGNOSIS . Chronic Respiratory Failure with Hypoxia CHIEF COMPLAINT (in patient's own words) / REASON FOR ADMISSION TO FACILITY · Resident stated," I had coughing and short of breath". PAST MEDICAL HISTORY · Seizure · Stroke EDUCATION NEEDS · Secretion clearance · Bleeding prevention . Aspiration prevention Medication order Generic name (Trade name) Dose Frequency Route PRN reason Metoprolol Tartrate (LOPRESSOR) oral tab 25mg give 1 tab via PEG-Tube every 12 hours Hold if SBP<110 or heart rate<60 Levetiracetam (KEPPRA) oral solution 100mg/ml give 10ml via PEG-Tube every 12hours Apixaban (Eliquis) oral tab 5mg give 1 tab via PEG- Tube every 12 hours RELEVANT SURGICAL HISTORY · Tracheostomy · Gastrostomy CURRENT MEDICATIONS Drug class Beta-Blockers, Beta-1 Selective Anticonvulsants Anticoagulants 1. Indications (Why your pt is taking drug; use rxlist.com) 2. Write 2 Nursing Considerations for this Drug 1. Resident has Dx of hypertension 2. Count Apical pulse for 1 full min prior giving this medication because very slow heartbeat is a common side effect, lightheadedness is common side effect 1. Resident has Dx of seizures 2. Monitor for episode of seizure activity, need to gradually decrease dosage if stop this medication, except severe side effect or allergy reaction 1. Resident has Dx of DVT and stroke 2. Monitor closely for S/S of bleeding, taking bleeding precaution, Premature Discontinuation increase risk of thrombotic events. ADMISSION DATA NOTES Directions: Include patient statements and abnormal findings only. If there aren't any patient statements
or abnormal findings, write 'N/A.' Relate abnormal findings to patient's medical diagnosis or PMH. Resident stated," I had coughing and short of breath" Pt was experiencing S/S of Respiratory Failure. (Mayo Clinic, 2023) ASSESSMENT DATA - LAB VALUES Directions: Indicate abnormal values as L (low) or H (high). If a lab value isn't available, indicate that section as 'N/A' instead of leaving it blank. Highlight abnormal findings; if abnormals aren't highlighted, it will be -0.25 pts per section. Note: 'M' indicates values for male patients. 'F' indicates values for female patients. Lab Value On Admission 5.76 HEMATOLOGY Lab Value Currently RBC M: 4.7 - 6.1 mm3 F: 4.2 - 5.4 mm3 Hgb M: 14 - 18 g/dL F: 12- 16 g/dL PLT 129 150 - 400K mm3 PTT N/A 30 - 40 seconds 17.1 2.94L WBC 5.0 - 10.0K mm3 8.3L Hct M: 42 - 52% F: 37 - 47% 415H PT 11 - 12.5 sec