NR 226 RUA Care Plan .docx - PATIENT ASSESSMENT STUDENT Harry Potter Sr Date of Care Client Age 73 years old Gender Male Resuscitation Status Full Code

NR 226 RUA Care Plan .docx - PATIENT ASSESSMENT STUDENT...

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P ATIENT A SSESSMENT Client Age: 73 years old Gender: Male Resuscitation Status: Full Code Allergies: NKDA Reason for Admission: Lethargic Medical Diagnoses: Coronary Artery Disease (CAD), Pressure Injury to Coccyx, and Diabetes Mellitus II Surgeries/Procedures and Dates: CABG x 4, 25 years ago, Automated Implantable Converter Defibrillator (AICD), 1 year ago Past medical history: Hypertension, Hyperlipidemia, Type II Diabetes, and ischemic cardiomegaly Pathophysiology Review: CAD is when plaque which is made of cholesterol builds up in the arteries. Pressure injury results from inadequate blood supply into the tissues. Diabetes Mellitus II results in hyperglycemia from insulin resistance Current Orders: Diet: Low fat/ Low Cholesterol Activity: One person assist with wheel chair Intake: 1800 ml Output: 1300 ml Accu Checks: Daily at bedtime Vital signs: 98.5 (T), 103 (HR), 107/70 (BP), 20 (R), 98% on room air Dressing changes/wound care: Daily wet to dry, cleanse open area to coccyx w/ NS, pat dry, and apply Allyn every other day on coccyx area, for Stage 3 ulcer: apply BID and PRN on coccyx area Most recent Imaging Findings: (CXR? CT? MRI?) Type of Imaging Body Area Imaged Reason for testing and results of test CT Chest Unremarkable no acute abnormal changes Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Why abnormal? 8/5 9/18 WBC 13.95 9.5 5,000-10,000 Infection on Coccyx 9/30 Glucose 252 60-120 Diabetes 8/5 HGB 13.6 12-16% (M) 12-16% (F) 8/5 HCT 41.2 42-52% (M) 37- 47% (F) 8/5 PLT 265 150,000-400,000 Other recent, significant procedures or tests (EKG, etc) Date Test Reason for testing and results of test 8/2018 Echo Cardiomyopathy EF: 15-20% Patient’s Developmental Stage according to Erikson: Ego Integrity vs. Despair Your assessment of this patient’s response to the opportunities and potential conflicts of this stage: 1 STUDENT: Harry Potter Sr._______________________ Date of Care: ____09/30/2019___________
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