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UNIVERSITY OF KENTUCKY COLLEGE OF NURSING NUR 863: PROFESSIONAL NURSING CARE ACROSS THE LIFESPAN INTERACTIVE CARE PLAN WORKSHEET Student Name: ______Macy Bundy________________________Mailbox___290_____ Patient’s Medical Diagnosis: R hip fracture 2˚ in shower fall Patient’s Initials: S.F. Sex: Female Age: 87 Wt.: 115 Ht. 5’ 2” STUDENT INSTRUCTIONS: In the space below enter the subjective and objective data related to the nursing diagnosis. Are the findings normal or abnormal? If abnormal include normal values for comparison.
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ASSESSM ENT Subjective Data Entry - “I can stand my pain to be a 4-5, but right now it is a 10.” - “When I have this nausea I don’t feel like doing any activities.” - “I have never taken a lot of medicines in my life, but the pain medicine seems to help when I get it.” - “Today it hasn’t mattered where I was, in bed or in my wheelchair.” Objective Data Entry BP: 120/68 (Normal) HR: 90 (Normal) RR: 22 (Abnormal; Normal = 12-20) Temp: 98.2˚ (Normal) SaO2: 97% (Normal) - Inhibited mobility r/t right hip fracture, WBAT, but uses w/c and walker AAT. (Abnormal; Normal = Full ROM wnl for older adult; should be weight bearing without the use of w/c or walker.) - Guarding, irritability, grunting with movement, moans with each step, nausea (Abnormal: Normal= no guarding, irritability, grunting or
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