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careplan medsurg 1 - Katy Hipps 1 WTAMU Division of Nursing...

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Katy Hipps 1 WTAMU Division of Nursing Nursing 3532 Care Plan Patient Initials _J.S _____ Gender ___Female ___ Age____85 _______ Room number _500 South __ Dates of Care 11/8/05 (DC’d to a rehab around 1800) Date of Admission _11/3/05 (From Northwest’s ED) ________________ Chief Complaint: On 11/8/05 her chief complaint was “ my legs are numb and weak” Admitting Diagnosis: On 11/03/05 R. Lateral pneumonia Poor nutrition Severe dehydration Confusion Past Medical/Psychiatric History: She has a history of COPD (diagnosis unknown), a history of thyroid disease (diagnosed on 8/11/05), HTN, Gastroesophageal reflux disease and UTI. Social support: She has no children (but she states otherwise at times) and is widowed, she does have a friend (unknown) who helps care for her. Admission Vital Signs: T (Rectal) 98.3 P _112 _ R _22 _ B/P _108/78 _Spo2: _91% Allergies: NKDA Weight ____90 lbs or 41 kg _______ Height __62’ ________________________ Special Orders: Nix treatment (for her lice) DNR & DNI Contact precautions (for her lice) Fall Precautions Call doctor if: HR >160 or <55 SBP >180 or <90 RR >30 Urine output < 5.5/kg/hr Fluid restriction: No 1
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Katy Hipps 2 I & O: On 11/08/05 her intake was __1350 _____ and her output was _unknown (a diaper) . It is unknown if her I & O’s are balanced. Diet: Regular with assistance Other: CT Scan of Brain w/o contrast on 11/2/05 Chest X-ray (2 views) 11/4/05 Urine Culture on 11/2/05 Blood Culture on 11/2/05 History of Present Illness: My patient is an 85 year old female who was brought to Northwest’s ED by the Amarillo police department, who had been called by the adult protective services stating that she had been living in neglected conditions. She has not been eating or drinking well for the past two weeks, so adult protective services thought she should be evaluated. Around 2000 on the 2 nd of November. Her past history is fairly sparse in what she remembers and there is little known about her past medical history. There is no history of her taking medicines, and she was almost impossible to get a review of systems, except that she stated her belly hurt, but did not specify where. She states that she does not have any chest pain or headache, vomiting, or diarrhea. Apparently she is a smoker and has a history of COPD (diagnosis unknown) as was noted by a previous x-rays. Her fingers are nicotine stained although she does not admit to smoking. She denies use of alcohol. There is very little about her past surgical history or her past social history, except that she lives alone. 2
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Katy Hipps 3 Pathophysiology COPD/ Emphysema Definition of disease: COPD-denotes a group of respiratory disorders characterized by chronic and recurrent obstruction of airflow in the pulmonary airways. Airflow obstruction is usually progressive, may be accompanied by airway hyperactivity, and may be partially reversible. COPD is referred to as the silent disease because symptoms generally progress slowly and almost imperceptibly. Emphysema is characterized by a loss of lung elasticity and abnormal enlargement of the air spaces distal to the terminal bronchioles, with destruction of the alveolar walls and capillary beds. Enlargement of the air spaces leads to hyperinflation of the lungs and produces an increase in total lung capacity.
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