Running head: NURSING CARE PLANNursing Care PlanOlalekan Johnson AdejolaCentennial College of Applied Arts and TechnologyPNUR 205Joseph MalunayMarch 22, 2021
Running head: NURSING CARE PLANBIOGRAPGIC DATAName: Mr. ABC.DOB: XX/05/1936Race: Caucasoid (white)Marital Status: WidowerContact Person: SonOccupation: RetiredSource of data: Primary (Interview) and Secondary (Patient’s Hospital Charting)Reason for seeking Care/Presenting Problem: Rectal bleed.Present Health Status:Current medical conditions/chronic illnesses: Rectal bleed, revascularization of right leg,leg cellulitis, DM-type 2, hypertension and stroke.Current medication: Acetaminophen, morphine, Cephalexin Keflex, hydrocortisone,metformin, dutasteride, amlodipine, perindopril, rosuvastatinMedication / food allergies: Acetylsalicylic acid (Aspirin)Current medical treatments: wound care and improving flow and perfusion of right leg.Past Health HistoryChildhood illnesses: N/APrevious medical condition: DM- type 2, hypertension, BPH, leg cellulitis, hypertensionand stroke.Previous hospitalization: BPH and stroke.Accidents/injuries: N/ASurgeries: Revascularization of right leg.Immunization: N/ADate of last examination: February 10, 2021Family history: UnknownPersonal and psychosocial history:Personal status: Full resuscitation statusFamily and social relationships: great family relationship with daughter living in the samebuildingDiet: Regular/Full dietFunctional ability: Complete bed rest at the moment due to SOB on exertionMental health: Normal LOCPersonal Habits:Tobacco use: N/AAlcohol: N/AStreet drugs: N/AHealth promotion:Exercise: Bed rest. Ambulation with sliding from bed to stretcherSelf-examination: Normal compared to patient’s baseline aside the SOB and lackof bowel movementOral hygiene practice: Mouthwash performed independently by the patient on thebed in high fowler positionScreening examination: N/AEnvironment: N/AReview of systems:
Running head: NURSING CARE PLANGeneral symptoms: SOB on exertion, respiratory rate on border and irregular heart rateIntegumentary system: Normal, no pressure ulcer or skin tearHead: round and symmetricalEyes: PERLLA, but patient using Timolol (eye drop) to treat pressure inside the eye dueto glaucomaEars: decreasing hearing ability.Nose, nasopharynx, Sinuses: NormalMouth: Moist membranes, no debenturesNeck: Normal Range of motionBreast: N/ACardiovascular system: Hypertension, hyperlipidemia, atrial fibrillationRespiratory system: SOB on exertion. Nasal cannula 2L/min O2 therapy.Gastrointestinal system: Constipation, very small feces over 36 hours.Urinary system: foley catheter insertedReproductive system: N/AMusculoskeletal system: Normal strength in both lower and upper extremities bilaterally.Central nervous system: N/AExamination:Vital signs: TPR 37.2, 72, 20, O2 sat 97% ON 2L/min O2 therapy via nasal cannula, BP140/80 mm Hg supine on left arm.
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