Horlds Narasi University Nursing Process Daily Care Plan High school STUDENT NAME_Vavel Piarapoda) DATE CLASS_FULDomepatal 6/4/2020_PATIENT ADMISSION DATE_Yasterbay Afternoon. GROUP C2530 PRSUBJECT_Care PAP INSTRUCTOR Inele gueroa Client Initials Culture/Ethnicity VR Support System/Siblings/Children & Ages Note American Son-Jonathan Russell/ 30 years old Unit/FACILITY Room/Bed Religion Neurological Unit Highest Grade Completed 0800 Wakan Tanka (the spirits) Age Sex Living Will CODE STATUS Advance Directive Quore Weight Marital Status Genogram (PEDIATRICS ONLY) 9.5 Kg single USE SEPARATE SHEET (Hospital Admission DX) OR (SNF Current DX Occupation Consultants? Name & specialty being treated for). Cashier. stroke with milo left Health Insurance hemiplegia Simply Current Work Status Name of Significant Other/Primary Caregiver unemployment Language English For (Hospital Setting: History of Present Illness) for (Skilled nursing facility : WHY is the patient in the SNF?) Male Height 178 cm Save to my Dropbox Ana Lewis Right size stroke, left hemiplegia Post Medical History and Past Surgical Procedures Hypertension, coronary artery disease beabetes mellitus type 2. Post history: Srooked over a pack of cigarretes per day for the past 35 years, and Does and bercise.
1 Nursing Process pack of cigarettes difficulty chain toll stay. List in Priority Order Beginning with #1 in Priority Assessment Date Subjective/Objective Nursing Diagnosis Plan Outcome Criteria Interventions (Client Centered) Rationale for Subjective: What does (Nurse Centered) Interventions Evaluation the patient say? Objective: What do you What is the problem? What is the goal for the What do you think The things you did, did it Why do you think this you’re going to do work or not work in patient for your shift? see? about it? will work? meeting the patient’s Subjective Data Stroke as goal? •Patient have • Patient will Place the betient This position in After 24 hours of evidenced by Smoked over a Iswallow ensepon- Puan upper right nimizes wesk for Misina intervention choking during two of the direlay Ave as evidence.by : past 3 years (dysphagia) hospital down slightly facelitating gravita .The patient shows Twhole Not exercise tional flow of food abelity to swallow AND neuromuscular eating and AND stomach and through sof by absence of Hypertension the pylo ves •Coronary artery Hemiplegia disease quite lower colchong bo choking with • Diabettes Mellitus sings of aspiration soes. eating And Drinking ora caupty after as much time for No food stasis for the Type 2. as those whose objective detai will decrease. the level of Aware- to eat And Madequate is added AND fluids eastly. Afher educates patient ness: X3. Ensure that some safety in the event be avai le touter- -Vital sug: -RR- 12 breath /min HR-1009 mew Reglsteny SPO2 97% educate thepte -P31/m2 risk Temp-97f/37c) Glucose level 65-700 ing/be) Σ weakness. Lept After 24 hours of Nursing interven position Generally patients aspiration, no patient’s • Provider Leating | Abelity to ingestros lowes stay with of choking or the best telephone aspiration mine different emerg- le procedure when choking occuers. bap CARE CAR Discu la C CADE tion the patient the of ay about Pothophysiology Clinical Critical Thinking Allergies/What reaction did the patient have meter and spasm of adjacenta o or buscador pf Diet with Rationale: (WHY IS PT ON THIS DIETE Diagnostic Procedures/Date Name and Results: and artherosclerosis coading to coronary The primary pathology pas the patient is hypertension other factor is diabetes mellores and Vital Signs/Frequency: Every 4 hans. RR 12, AR-96, BP-134/2mm Hg T- AF those risk factors conducted the hauts shorts Ap-12,AR – 96 P – 1948 mm 1987- 9970 blood leak from a blood vessels or hervorrhage muld the 22-12/HR – 97, BP-1360) /mor 17-9976 brain tissue, causing edema, The brain the vessels. Intractoneal her I Asked the patient about any meer best compromise bre function: Impormas en ral allergie And he replied “No I am not allergic to anything? Zes on the left side of the No Allergies. The patient is on nothing by mouth except for medications 6/4/2020 -Lumbar punture rule out menpugitis Duster swallow study comble en Bogateve – Subarochnos hemorrhage (Tornography scowwrong.) tomorrow. Speech therapa? Swallow study 16/4 2020 Transcranial Doppler evaluate the velocity of blood flow kctivity order, AND Identify the location and degree of arten occlusion. Up to chair, up to bathroom assistand 64/2020 Cavotio artery duplex scanning, measures flow Physical therapy. – Incese ochesly to tolerated through the conotis arteries, iden identifying 10/4/2020 • Cerebral blood flow studies measures blood flow Walker to the brain. 6/4/2020 • Electrocardiography, evaluates electrical achiely yetioning to lifeting positioning PN the cortical infarction. 6/4/2020 – Fibeurolytic therapy should not be delayed while waiting for result. DIA Limitations/Prosthetic Devices: blood flow. Duties that you would delegate to medical dressind 3 CARE After shoke in the right hemisphesh the patient is paraly- Vital Signs: T: 29 HR: 100 heg Assessment: 100 R: 12 B/P: 132/80 mm Hg Pain: ‘No pain. PN scale o to 10. Rating Scale: Quality: Location: *FOR OB ONLY Postpartal Assessment (Vaginal or C-S: Homan’s Sign: B’ Breast: Breastfeeding Assessment: Appropriate Position: YES O NO Feeding Observed: YES O NO O Lactation Consultant: YES O NO Neurological & Cognitive : HEENT His Neurological check are stable AND he continues to have milo left hemiplegia. HANDS greps are almost egual but lette weaker a Cardiovascular. X* 29you are the set to light. Orellas Uterus. auscultation heart for irregular chytim and abnormal rate murmurand auscultation por cerobo artery was perfoorn. Everything, normal range, the pulse is reguler but strong. Ayoutate lungs. . 12 buat per minute. Normal origen saturation 97%. Normal. Bowel: Bottlefeeding: YES NO O Baby in NICU: YES NO O Bladder: Maternal/Infant Bonding: Appropriate Eye Contact and Touching: YES NO O GI/Bowel: Lochia: Dornal bond sound ofter percusion Not sign, of incontinence. AND aus uiltation. GU/Bladder: Polyuria because diabetes mellitus, NA incentiNorce. Normal elasticity of the skins Nornal color of the sken Not sweating. Not massoss. Perineal/Rectal Skin: Х Abnormal Laboratory Data: Lab Test #1 Abnormal Laboratory Data: Lab Test #2 Abnormal Laboratory Data: Lab Test #3 Abnormal Laboratory Data: Lab Test #4 Results: Results: Results: Results: N/A What is the cause for the Abnormal Results? What is the cause for the Abnormal Results? What is the couse for the Abnormal Results? What is the cause for the Abnormal Results? USE THE SYMBOLS Intravenous Solution #1 gtts/min Type_capoje Sodium CC/HR: 125/60 Labs: (Date, Current ,Previous, ) additives: DomSobium_Rationale for solution: 0.9% IV. ptoday ASAP CBC, Chempanel (HCP) Chloride prothrombin time (Pt) IV Heplock Site: forearm Date: 6/4/2020 Tubing Changed: 64 -8100 PM Date/Time IV D/C’d: 6/4 2:05 Date/Time loTwide a IV Restart:67 7.00 Pay Date/Time Day blood glucouse (H6.41c) | bedside) Attempts: If IV siłe swollen), 52-Afcon nue. Do not flush Site: forearen Gauge: 19- Х Medication Name Trade/Generic Classifications Dosage Ordered Adverse Affects Dose Route/Frequency Indication Nursing Implications What must be done prior to administration? Sodium choride solution for 100 ml/hr Febrite raspasse IV- 100 ML.he Introwenous. Correct dosege, I fluid (IV) Thypercolonia thrombosis. at the site expection of venous Losarton Polssium pill (orally) / song D122 Ness or twice dolly lightheadedress orally orally. chest pain Hypooly omia Metformin pill Corelly) 500 mg Dianthea vo- twice daily mitin, nausea orally [flatulence Orally equipment. Educate the Ipatient about the side effect of this medication explain the patient this mattico dion. Stay with the patient at the moment to take medication Chlorthalisome pillCorally) asing * Diarchea, nausea Dally orally Orally. appetite, pizziness (once daily neadeche, constipa tion, stomach erempPng op ulcerations Daily Corally) Orally Abdominal pain, Conce daily) u cramping headache, nausea bleeding Holo until Lab comes back tomorrow Q-m. | Aspirine pill (orally) sing Red flag) Gastritis CARE CARE es NURSES NOTES: Must contain Date, Time, entry, then signature at of each encounter, must be in chronological order. Document care of the clients carel condition throughout the shift. Time : Date : 6/4/2020 7:00 AM Signature: was taken overy 4 hours. Measures was documentes in th medical motor ds. Nosological assessment w205. DONO showing significant change Pn his status. Patient continue in stable conditions. Lab test indicated. Delegated task to the LPN about assisting the patient during topleting positioning and ambulation. 0 ARE ARE. Get Nursing Assignments Help