Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma.
Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
1) What were the nursing NANDA nursing diagnoses?
2) What goals did you assign to this patient?
3) What priority nursing actions apply to the case study (Saunders document along with page number) as applies.
a. If there is NO Saunders for the topic then you can write own priorities.
4) Develop a short NCP on your patient to include:
a. Case study
b. Assessment data (from the case study)
c. 3 priority NANDA nursing diagnoses
Current pertinent assessment data using head to toe approach, pertinent diagnostic, vitals signs
Any orders or recommendations you may have for this patient
Concept Map work sheet
Describe disease process affecting patient
(Include pathophysiology of disease process)
(reason for test & results)
Anticipated physical findings
Anticipated nursing interventions
Patient education worksheet
Name of medication, Classification, and include prototype
Safe dose or dose range, safe route
Purpose for taking this medication
Patient education while taking this medication
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