Major Care Plan
Student Name: Jane Doe
Date of Care: 10/15/13
Pt. Initials: RC
Rm #: 453-2
Chief Complaint: Abdominal Pain
Medical Diagnosis: Acute Appendicitis/Laparoscopic Appendectomy BCF’s & Power Components
Unable or Unwilling:
1. Age: 64 years
2. Gender: Male
3. Developmental State: a. (Erikson Theory) Integrity vs. Despair. b. Cognitive: Alert/Oriented x 4, long and short-term memory in tact. c. Physical: Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
4. Relevant Life Experience: Type-2 Diabetic; smoker in process of quitting (currently using nicotine patch); CABG 2008
5. Health Care System: Pt arrived at emergency room approximately 04:00 on 10/12/13 with sharp right side abdominal pain 9/10 on pain scale, nausea, and vomiting, Temp: 99.2F. Abdominal U/S confirmed inflamed appendix.
6. Health State: Admitted at 14:36 and appendectomy surgery performed from 19:32 to 20:50 on 10/12/13. Assessment findings: BP 136/83, HR 86, RR 14, O2 Sat 96 on oxygen 2L nasal cannula, Temp 98.4F, abd pain 3/10. Lungs: clear and equal breath sounds; apical pulse: auscultated, strong, regular; pulses: equal, regular, strong radial and pedal sites, no edema. Capillary refill immediate (less than 2 seconds). Negative Homan sign bilaterally. Pt expresses interest in leaving hospital as soon as possible. Labs: last accu-check 18:46 on 10/14/13: BG 114. Soft diet. Weight: 225 lbs. (102 kg); Height: 5’11”; BMI: 31.4 (obese)
7. Socio-Cultural Orientation: Caucasian male, divorced, lives alone, has two grown daughters in their 30’s who live in California. Girlfriend is ER Registered Nurse of 20 years, at AV Hospital. He is a retired mechanic. No religious affiliation.
8. Available Resources: Blue Cross HMO insurance. Lives on sufficient retirement funds and social security.
1. Aware Of Self & Surrounding: Alert and oriented to person, place, time, and situation (x4). Long and short term memory in tact.
2. Physical Energy To Care Out Self-Care Actions: Has sufficient energy when pain is under control. Small amount of activity, such as changing clothes or up to restroom, is tolerated moderately.
3. Ability To Control Body Position & Movements: Ambulates unassisted, has full range of motion all extremities. Changing positions and rising from or lowering to bed/chair is difficult due to abdominal tenderness.
4. Ability To Reason: Has ability to reason, responds appropriately to questions and is aware of surroundings; understands pain scale. Long and short term memory in tact.
5. Motivation: Pt wishes to fully recover quickly to resume socialization with girlfriend, family, and friends. He is currently using nicotine patch to quit smoking (x6 weeks smoke-free).
6. Ability To Make & Implement Decisions Regarding Self-Care: Able to make decisions for himself. He realizes recovery will need to be slow and careful.
7. Ability To Acquire, Retain & Utilize Knowledge: Has sufficient long and short-term memory and good attention span. He asks and answers questions of health care team regarding his health status; demonstrates acquired knowledge through verbalization and complying with medication administration.
8. Repertoire Of Skills: Is able to perform ADL’s such as dressing, ambulating to bathroom, and taking required medications, with decreasing difficulty.
9. Ability To Order Self Care Actions: Patient is aware of physical limitations and calls on his girlfriend, who is an RN with 20 years experience, when he has a question regarding his health. He does not like to go to the hospital and only did so because she told him he must go.
10. Ability To Perform Self Care Actions Consistently: Consistently takes prescribed medications at home; has quit smoking for 6 weeks.
IV site without redness or swelling.
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