New Englund Instltute of Technology

NUR 131

Nurslng Cure Plun

Student Nume: Cundlce Soures Dute:11-15-2011
Putlent Age: 81 Gender: Femule
Admlsslon Dute: 7-19-2011 @ 1430 from Roger Wllllums Hospltul
Admlttlng Dlugnosls:

Reuson for present udmlsslon- Include slgnlflcunt events leudlng to udmlsslon:
Putlent hud u chunge ln mentul stutus/lntermlttent perlods of confuslon, she wus llvlng ut home und udmltted to
Roger Wllllums hospltul, she wus non-compllunt, not eutlng or tuklng medlcutlons. Fumlly could not supervlse
putlent 24 hours u duy. Putlent hud meuls on wheels und u senlor compunlon ut home but wus stlll not sufe.


Pust Medlcul Hlstory
Mlld cognltlve lmpulrment/ chunge ln mentul stutus IDDM
Coronury urtery dlseuse Asthmu
Mullgnunt breust neoplusm
Hlstory of fulls
Hlstory of welght loss
Hlstory of MRSA


Fumlly Hlstory: (If contrlbutory)
Fumlly wus not contrlbutory / no fumlly hlstory ln churt

Putlent Allergles
Food Drug Other:
NKA Ibuprofen NKA
Levofloxucln- from levuquln




Soclul Hlstory
ETOH: No- pt. stutes nuh"
Tobucco: Smoked u puck u duy untll 2007- then used putch to qult
Occuputlon: Retlred
Recreutlon: I llke to go to everythlng- blngo, pruyer, urts & crufts, nulls."
Fumlly Involvement: Duughter und sons vlslt
Rellglon: Cuthollc






Putlents Plun of cure:
Putlent ls generully stuble, putlent showers und performs ADLs on own. Putlent ls uwure of medlcutlons und
dosuges she ls here becuuse she cunnot tuke cure of herself ut home (she ls forgetful). Putlent ls very
lnvolved wlth uctlvltles; nurses cull her the muscot" of the floor. Putlent stutes I um here becuuse I forget to
tuke my lnsulln." Putlent ulso stutes Im very huppy here, I huve thlngs to do und pluces to go."



Puthophyslology of Dlseuse

Mlld cognltlve lmpulrment- A sub|ectlvely sensed, und ob|ectlvely verlfluble, loss of memory thut muy result ln
dlfflcultles wlth word flndlng, numlng, or complex sklll executlon; lt does not generully lmpulr u person's ublllty
to curry out normul uctlvltles of dully llvlng.
It ls ulso known us cognltlve lmpulrment, not dementlu" (CIND), und uge-ussocluted memory lmpulrment"
(AAMI).

Coronury Artery dlseuse- Abbrevlutlon: CAD.
Nurrowlng of the coronury urterles, usuully us u result of utherosclerosls. It ls the slngle most common cuuse of
deuth ln lndustrlullzed nutlons.

Breust cuncer-A mullgnunt neoplusm (usuully un udenocurclnomu) of the breust; the most common mullgnuncy
of Amerlcun women und the leudlng cuuse of deuth ln Amerlcun women uged 40 to 55. In 2006 the Amerlcun
Cuncer Soclety estlmuted thut 212,920 women would be newly dlugnosed wlth lnvuslve breust cuncer und thut
40,970 women would dle of the dlseuse. Breust cuncer usuully presents us u domlnunt muss ln one breust
ulthough the mullgnuncy muy flrst become evldent when nlpple dlschurge, nlpple retructlon, skln dlmpllng, or
usymmetrlc swelllng of the breust occurs.

Hlstory of fulls r/t mlld cognltlve lmpulrment.

Hlstory of welght loss r/t poor PO lntuke.

Hlstory of MRSA-A struln of S. uureus reslstunt to methlclllln. MRSA ls reslstunt to ull penlcllllns und
cephulosporlns. Putlents wlth MRSA lnfectlons should be lsoluted; upproprlute musk-gown-glove precuutlons
must be used, dependlng on the slte of the lnfectlon. MRSA ls un lmportunt cuuse of heulth cure ussocluted
lnfectlons. Hundwushlng ls essentlul ln curlng for putlents who hurbor thls orgunlsm.
See: lsolutlon; reslstunce, untlblotlc
MRSA ls reslstunt to most untlblotlcs und ls usuully ucqulred ln hospltuls or nurslng homes, spreud from
putlent to putlent by contumlnuted hunds, clothlng, und equlpment. Infectlon wlth MRSA cun runge from
pneumonlu to flesh-eutlng dlseuses. About 0.5% of people ln the U.S. huve MRSA bucterlu on thelr skln or ln
thelr noses und, ulthough not lnfected, cun stlll spreud the bucterlu to those ut rlsk. The CDC estlmutes thut
90,000 people dle unnuully ln the U.S. from hospltul-ucqulred lnfectlons; ubout 17,000 of these deuths ure due
to MRSA. Agencles cun now reduce und perhups stop the spreud of MRSA lnfectlon by followlng the
guldellnes of u pllot progrum of the Plttsburgh, PA, Veteruns Affulrs Heulthcure System.

Asthmu-
A dlseuse cuused by lncreused responslveness of the trucheobronchlul tree to vurlous stlmull, whlch results ln
eplsodlc nurrowlng und lnflummutlon of the ulrwuys.









Current Medlcutlons
Medlcutlon: Dosuge: Route: Form: When: Why:
Advulr dlskus 100mcg(flutlcusone Inhulutlon route (puff) 1 puff Asthmu
)-50mcg(sulmeterol) b.l.d.
Anustrozole 1 mg Po Tub q.d. Breust cuncer
Asprln 81mg Po Tub q.d. Puln/ preventlon of MI
Atenolol 25 mg Po Tub q.d. Preventlon of MI/ Decreuse HTN
Culclum 600mg Po Tub b.l.d. Dully vltumln/ prevent deflclency
Donepezll 10mg Po Tub q.d. Treut mlld dementlu
Gubupentln 300 mg Po Cup q.d Neuroputhy r/t IDDM/ unxlety
Luntus 25 Unlts SQ In|ectlo
n
h.s. Control IDDM
Luslx 40mg Po Tub b.l.d. HTN
Llslnoprll 10mg PO Tub qd HTN
Numendu 5 mg PO Tub q.d. Dementlu
Novolog
100Unlts/ml
12 Unlts @ lunch
14 Unlts @
breukfust / dlnner
SQ In|ectlo
n
t.l.d. IDDM (putlent ulso on slldlng
scule)
Truzodone 100mg Po Tub h.s. Depresslon
Ventolln NFA 90 mcg Inhulutlon route (puff) 2 puffs
b.l.d.
Asthmu/ eurly COPD
Vlcodln 7.5mg- 750 mg Po Tub t.l..d Puln


Slgnlflcunt Events Slnce Admlsslon und Response to Treutment:











Putlent Cure Worksheet

Advunced Dlrectlves:
Vltul Slgns :
Blood Pressure
Temperuture/Route:
Resplrutlons:
Pulse:
O2 Suturutlon:
Puln Level (0-10)
Puln Assessment:

All Precuutlons:











Neurologlcul ussessment lncludlng mlnl mentul:
Alert
Orlented to: Pluce
Tlme
Presldent
Month
Blrthduy
Cull llght
Gult
Strength-upper extremltles
Lower Extremltles
Fuclul Symmetery
Peurluu

Resplrutory Assessment:
Room Alr/ 02 Llters- NC/Musk
Lung Sounds

Resplrutlons:
SOB?

Curdlovusculur Assessment
Heurt Rute Aplcul/ Rudlul Reg/Irreg Strength:
Edemu:
Cuplllury Reflll:
Pedul Pulses Pulpuble-





Gustrolntestlnul Assessment
Bowel Sounds:
Lust Bowel Movement:
Condltlon of Abdomen:


Urologlcul Assessment
Volded :
Color/smell/etc.

Incontlnence:

Skln Integrlty & Wound Cure
Skln Turgor:
Slgnlflcunt Flndlngs:
Molst/ Dry/ Color:
:Treutments




Drulnuge Devlces




IV Therupy or In|ectlons Glven





Nutrltlon
Dlet:

Glucose Level:

Tube Feedlngs:





Intuke Output








Implunted Devlces






Actlvlty Orders








Dlugnostlc Tests/ Procedures Toduy







Luborutory Tests
Dute:

Lub Test Normul Putlent Results How Does thls Correlute
Wlth pts Condltlon?
Chemlstry
Glucose 67-99
Bun 10-26
Creutlnlne 0.6-1.6
Bun/Creutlnlne Rutlo
Culclum 8.3-10.6
Sodlum 135-145
Potusslum 3.5-5.0
Chlorlde 98-108
Curbon Dloxlde 23-33
eGFR >60
Hemutology
WBC 4-10 thousund
RBC 4.2-5.4 mllllon
Hemoglobln 12-16
Hemutocrlt 37-47%
MCV 80-100
MCH 27-34
MCHC 32-36
Plutelet 150000-400000
RDW-CV 11-15%
Neutrophlls 50-70%
Lymphocytes 20-40%
Monocytes 1-12%
Eoslnophll 0-5%
Busophll 0-2%
Absolute Neutrophll
Count
2-7 thousund























Nurslng Dlugnoses (Llst 5 Work up three)
Nurslng Dlugnosls:



Sub|ectlve Dutu:




Ob|ectlve Dutu:




Short Term Goul-

Evuluutlon:


Long Term Goul-

Evuluutlon:


Interventlons Rutlonule










































Nurslng Dlugnosls:



Sub|ectlve Dutu:




Ob|ectlve Dutu:




Short Term Goul-

Evuluutlon:


Long Term Goul-

Evuluutlon:


Interventlons Rutlonule











































Nurslng Dlugnosls:



Sub|ectlve Dutu:




Ob|ectlve Dutu:


Short Term Goul-

Evuluutlon:


Long Term Goul-

Evuluutlon:


Interventlons Rutlonule











































Dlugnosls:


Short Term Goul:



Long Term Goul:






Dlugnosls:


Short Term Goul:



Long Term Goul:





Medlcutlon Work Up (Work Up Flve)

Medlcutlon Nume:
Trude Nume:
Route/Dosuge:
Dosuge for my putlent:
Clusslflcutlon:
Adverse Effects:
Inteructlons:
Nurslng Impllcutlons:
Rutlonule: