Clinical Journal and Care Plan
Clinical Preparation & Journal Form
1. Biographical Data: DOB: 09/25/1959, Female, 61 y.o.a.
Age & Sex: 61 years and female
Culture and Religion: Christian
Living Arrangements: nursing home
People in Home (number and relationship): 1 roommate
Reason for hospitalization: MRSA isolation, Post-op or left knee replacement
Past Health History (other hospitalizations & surgeries): Right knee replacement (2010). Hysterectomy, Cholecystectomy
Date of admission: 10/12/2011
Admitting Diagnosis: Macular degeneration, COPD, Asthma, GERD, Rheumatoid arthritis, Hypertension
Anticipated Nursing Plan of Care: maintain airway patency,enhance nutritional intake, relieve and control painprevent or minimize development of myocardial complication.
Frequency of Vital Signs: once daily
Activity: activity is as tolerated by pt.
Expected Nursing Care: Nursing care is to ensure pt pain level is as low as possible. Help pt get back to her normal life.
Anatomy, Physiology and Pathophysiology related to patients admitting diagnosis: patient’s legs were swollen and edema also noted around the legs because of the surgry, patient also has impaired airway clearanceas a result of asthma and copd.
General Appearance: the pt. is clean and well groomed had a shower this morning. Hair is free of dirt, lumps or masses. Hair looks health, facial features are symmetrical, and mouth is clean and free of any odor. pt able to perform adl with minimal assistance. skin around arm, leg and abdomen is clean, free of bruises, bumps or cuts.
Vital Signs: 134/77, temp=98.1, p= 70, and respiration = 20.
Comfort: the pt. states that she was comfortable as pain was properly managed by the health care team.
Communication: alert and clear
Cardiovascular: the pt has some form of hypertension. The blood pressure is a little high, but in all the vital sign this morning is normal.
Respiratory: the pt has clear and strong breath sounds and also normal on auscultation. On percussions I could hear resonance.
Genitourinary: not done
Gastrointestinal: on inspection the abdomen is symmetrical, with no abnormal swelling, no bruises. On auscultation bowel sounds present on all 4 quadrants. On percussion tympany was heard on all quadrant.
Skin/Wound. The surgical wound area looks clean and dry, with the sterile strips in place. Edemaof about 2+ present at the ankle and around leg.
Neurological: I checked her reflexes they were normal.
Musculoskeletal: physical therapy did ROM as tolerated by the pt.
Activity: activity tolerance was encouraging.
Access Devices: none
Equipment: wheel chair, ice pack. And other physical therapy equipment.
Abnormal Lab and/or X-ray results/Significance to diagnosis: a lab test was done to check for MRSA and was negative for the 2nd time.
5. Medication Sheet.
1. Name(s) of Medication: Prinivil / lisinopril
Pharmacological Action: blocks the conversion of angiotensin 1to the vasoconstrictor angiotensin 11
Use (for your patient): hypertension
Route and Dosage: PO. 20mg once daily can be increased up to 20- 40
Is this a safe dosage? yes
Is this dose within recommended range? yes
Contraindications and Precautions: contraindicated in hypersensitivity, history of angioedema with previous use of ACEinhibitors, can cause death to fetus, use cautiously in renal impairment, hepatic impairment.
Potential Adverse Side Effects: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. edema
Side effects seen with your patient: edema, fatigue, headache.
Applicable lab values:
Nursing Implications: monitor blood pressure...
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