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Care Plan for PatientTerm Paper

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Care Plan

Patient Introduction:

The patient is a 85-95 years old Caucasian male who admitted to an acute rehab facility on April 11, 2016 after suffering a syncopal episode (loss of consciousness) and fell in the dining hall at Brighton Gardens nursing home. Patient has no memory of the events surrounding the fall and transporting to the hospital. He stated last thing he remembered was sitting in the dining hall with other residents and when he woke up he was already in the hospital.

Prior to his admission into the rehab facility, the patient was brought to Suburban hospital on April 4, 2016 after suffering a syncopal episode and stayed at the hospital for a week. While he was into the hospital, he had loop recorder placed to record arrhythmia. He also had ultra sound of the carotid arteries, Magnetic Resonance Imaging (MRI) of the brain, Magnetic Resonance Angiogram (MRA) of the head and Computerized tomography (CT). The ultrasound showed calcified plaque without hemodynamically significant stenosis of the right and left internal carotid arteries. The MRI showed atrophy and small vessel ischemic changes and no definite acute intracranial abnormality, which indicated transient ischemic attack. The MRA showed normal MR angiography of the circle of Willis. The CT of brain and head showed no acute intracranial abnormality including no acute hemorrhage or identified recent territorial infarct was seen. The CTA of chest showed no evidence of pulmonary embolus or acute inflammatory process in the chest, stable atelectasis at the right lung base, and right thyroid nodule.

The patient's past medical history includes hyperlipidemia, hypertension, atrial fibrillation, coronary artery disease, myocardial infarction, chronic kidney disease, benign prostatic hyperplasia, and irritable bowel syndrome. In 1997, he had two surgeries done: coronary artery bypass grafting and removing bladder stones.

The patient was born and raised in Pennsylvania, then moved to Maryland with his wife and two sons in 1970. He was in the army for two years after finishing high school. Then, he was a carpenter and in construction business for some time before he went to business school and graduated with an accounting degree. He met his wife while working as an accountant in Pennsylvania. They had been married for fifty-two years, she passed away ten years ago. He stated that both his parents had passed away: father died in his 50s from "stomach ulcer" and mother died in her 70s from stroke. He stated he started to drink and smoke when he was in the army, but quitted smoking and drinking in 1954 when he started to get chest pain and her wife asked him to stop. He used to smoke a pack per day.

Due to his syncopal episode, the patient cannot perform activities of daily living without assistance. He can bed bath and feed himself; however he needs to have someone assists him with walking to a bathroom. He can walk a short distance with a walker, but sometimes he needs to be in a wheelchair. At the rehab facility, he reported experiencing vertigo and weakness with his lower extremities bilaterally. He also stated he usually has pain on his legs every day when the evening time comes which prevents him to do any activities.

The patient does not have any known allergies. The patient's code status is full code.

Assessment and Interpretation:

April 23, 2016 13:00 Head-to-Toe Assessment

Assessment

Problems:

Vital Signs:

Temperature: 96.6 F (Oral)

Heart Rate: 65 beats per minute

Respirations: 20 breaths per minute

Blood Pressure: 152/76 mm

SpO2: 98% (Room Air)

Decreased cardiac output r/t atrial fibrillation and hypertension AEB increased blood pressure (Doenges et al., 2013, p. 172-173).

Psychosocial:

Posture is erect in bed and position is relaxed. Patient is awake, alert, and aware of stimuli. Patient's facial expression and speech is appropriated. Patient's mood and affect is mellow, but hopeless. Patient stated "I will never get out of here." Recent memory and remote memories intact. Patient can give great details of his life history. Thought coherent.

Hopelessness r/t prolonged activity resection, deteriorating physiological condition, loss of self-independence AEB patient believes things will not get better for him and patient stated "I will never get out of here" (Doenges et al., 2013, p. 485-486).

Neurologic:

Alert and oriented to person, place, time and situation.

Cranial Nerves:

I -- Not assessed.

II -- Test suggests peripheral vision intact

III, IV, VI -- Extraocular muscles intact. Pupils are equally round, reactive to light and accommodation bilaterally. Eye movement is parallel. No nystagmus.

V -- Not assessed.

VII -- Patient can smile, frown and puff up his cheeks.

VIII -- Patient can hear when talking.

IX, X -- Not assessed.

XI -- Patient can lift both shoulders against resistance.

XII -- Patient can say "light, tight, dynamite." "

Gait: Observed when the patient went to the bathroom. He walked with a walker and had a nursing assistance with him. All extremities are symmetric bilaterally. Patient can move his extremities with full range of motion and can feel sensation all around his body throughout the assessment when touch.

Musculoskeletal:

Patient's joints and muscles symmetric. No joint swelling, redness, masses, deformity. Full range of motion in all extremities; however, muscle strength is rated 5/5 equally in upper extremities and 3/5 equally in lower extremities. Patient's body movements are slow when walking to the bathroom with a walker and a supervisor. Patient stated having stabbing pain on his lower extremities every evening time.

Impaired physical mobility r/t decreased muscle strength, pain on his legs, activity intolerance and deconditioning AEB slowed movement, postural instability -- standing and walking, inability to move or transfer (Doenges et al., 2013, p. 611-612).

Self-care deficit: bathing, dressing, feeding, toileting r/t muscle weakness on lower extremities, pain on his legs, impaired mobility AEB inability to perform ADLs -- inability to get to the bathroom independently (Doenges et al., 2013, p. 787-788).

Impaired comfort r/t stabbing pain on patient's legs that he gets every evening AEB self-reported of being uncomfortable, lack of ease in situation and disturbed sleep pattern (Doenges et al., 2013, p. 210-211).

Cardiovascular:

Precordium: no abnormal pulsations and no heaves. Carotid artery pulses are 2+ bilaterally, no bruits, no apical pulsation and apical pulse heard at 5th intercostal space at the midclavicular line with normal rate and rhythm; heart sound was normal S1 and S2. No S3, S4 or murmur. Skin on extremities is dry, intact, no lesion, symmetric, no edema on upper and lower extremities. Radial pulses are 2+ bilaterally, dorsalis pedis and posterior tibial pluses are 2+ bilaterally; capillary refill is less than 3 seconds in all the upper and lower extremities with warm temperature. Localized hypothermia is felt on both feet.

Ineffective peripheral tissue perfusion r/t hypertension and sedentary lifestyle AEB self-reported of pain and decreased temperature in lower extremities (Doenges et al., 2013, p. 957-958).

Respiratory:

No abnormal breath sounds, lung sounds are clear throughout lung fields to auscultation. No masses noted upon palpation of anterior thorax.

Gastrointestinal:

Abdomen is flat, non-distend and symmetric. Skin is smooth with no lesions, scars, or striae. Bowel sounds present, no bruits. Abdomen is soft, no mass or tenderness upon light palpation. No pain reported.

Genitourinary:

The patient uses urinal while lying in bed. Patient's urination is light yellow color and clear. Patient reported of his usual urinary pattern -- 3-4 times a day.

Integumentary:

Skin: color is appropriated to patient's ethnicity, warm, dry, intact, even, smooth throughout body; no lesions. No pallor, erythema, cyanosis, or jaundice. There were surgical scars on his chest. Hair: grey color, even distribution with good texture. Nails: no clubbing / cyanosis, capillary refill is less than 3 seconds bilaterally. Localized hypothermia is felt on both feet.

Ineffective peripheral tissue perfusion r/t hypertension and sedentary lifestyle AEB self-reported of pain and decreased temperature in lower extremities (Doenges et al., 2013, p. 957-958).

Risk for impaired skin integrity r/t hypothermia on lower extremities, physical immobility and incontinence (Doenges et al., 2013, p. 864).

HEENT:

Head: normocephalic. Face: symmetric. Eye: conjunctivae clear and sclera white. No lesion or redness. Ears: pinna - no mass, lesions, discharge or tenderness to palpation. Neck: supple with full ROM, no mass. Trachea: midline. Mouth: mucosa and gingivae pink and moist; tongue symmetric, protrudes midline.

Lab Results:

Lab and radiology data results are correctly interpreted in light of the patient's history and current condition. Normal and abnormal interpretation of lab and radiology data is interpreted and discussed for significance to patient status and disease pathology. Preferably looking at multiple dates for comparative analysis. If lab/diagnostic data is unavailable, discuss what would be warranted or recommended with appropriate cited rationale (REFERENCES NOT OLDER THAN 5 YEARS).

For example: labs, why is it normal or why would it be high/low according to patient history and current condition. The patient has low hemoglobin and hematocrit because they are anemic.

Lab

Patient Value 04/12/16

Patient Value

Normal Range

Significance

Sodium

136-145

Within Range

Potassium

3.7

3.5-5.5

Within Range

Chloride

98

98-110

Within Range

Carbon Dioxide

28

21-31

Within Range

Anion… [END OF PREVIEW]

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