Care Plan example

Topics: Nursing care plan, Nursing, Hypertension Pages: 9 (1270 words) Published: February 28, 2014
 PN 0004C Weekly Clinical Planning Sheet Student Name: S.H Care plan #5 Patient Initials: t.l

Age/Sex: 73/f
Allergies: Potassium
Nurse on Duty: Regin
Admission Date: 06/29/2013
Admitting Physician: Dr. Cole
Consulting physician:
Code status: Hospice, dnr
Activity Level: As tolerated
Diet: nectar thick/puree
Patient History and Diagnoses: primary dx: cva.

Patient admitted to coral bay 06/29/2013 with a primary diagnosis of CVA. Patient’s HX includes uti, bipolar, hypertension, chest pain and difficulty walking. Patient is married and resides at home. She is ambulatory and does not smoke. She is a does not drink, and does not do illegal drugs. Mrs. T.L has a sedentary lifestyle, she has a desk job and enjoys watching cooking networks.

Pathophysiology:
The primary pathophysiology of stoke is an underlying heart or blood vessel disease. The secondary manifestations in the brain are the result of one or more of these underlying diseases or risk factors. The primary pathologies include hypertension, atherosclerosis leading to coronary artery disease, dyslipidemia, heart disease, and hyperlipidemia. The two types of stroke that result from these disease states are ischemic and hemorrhagic strokes. A stroke is the sudden onset of weakness, numbness, paralysis, slurred speech, aphasia, problems with vision and other manifestations of a sudden interruption of blood flow to a particular area of the brain. The ischemic area involved determines the type of focal deficit that is seen in the patient.

S/S: Weakness or total inability to move a body part, numbness, loss of sensation, tingling or other abnormal sensations, decreased or loss of vision, language difficulties, inability to recognize or identify sensory stimuli and loss of memory.

Treatment: The most effective treatment for stroke is intravenous rtPA. This medicine works to dissolve the clot causing the stroke. If received within 3 hours of the first stroke symptoms, the drug can help prevent permanent problem.

Nursing diagnosis pertaining to primary diagnosis
Impaired cerebral tissue perfusion
1. Risk for ineffective airway clearance
2. Impaired physical mobility
3. Risk for impaired verbal communication
4. Risk for disturbed sensory perception (tactile)

References:

1. PATHOPHYSIOLOGY REFERENCE: PATHOPHYSIOLOGY OF A CVA/STROKE. RETRIEVED 11/19/2013 HTTP://WWW.AMEPC.ORG/CVA

2. MEDICATION REFERENCE: SKIDMORE, L. (2011). NURSING DRUG REFERENCE. ST. LOUIS, MI. ELSEVIER. MOLBY

3. LAB AND DIAGNOSTIC REFERENCE: LEFEVER, J.K. (2011). HAND BOOK OF LABORATORY AND DIAGNOSTIC TESTS, NJ. PRENTICE HALL

4. NURSING DIAGNOSES REFERENCE: GULNICK, M. AND MYERS, J. (2011). NURSING CARE PLANS, DIAGNOSES, INTERVENTIONS, AND OUTCOMES. CHICAGO, ILLINOIS. ELSEVIER

Vital Signs:
0830
Temp
98.2
Pulse
66
Respirations
17
Blood Pressure
144/88
Pain Level
4

Medications

Medication Name
(trade & Generic names)
Dosage
Is this a safe dose?
Frequency
Route
(how do you give it?)
Classification and Primary Action of Medication
(Why is this patient receiving this drug and what is the therapeutic class?) Nursing Implications/Side Effects
(What should the nurse do prior to giving any medication and especially this medication and what are the side effects common to this drug?) Famotidine
(Pepcid)
20mg
Adult
300mg
QD
PO
Antiulcer agent

Inhibits the action of the H2 receptor site located primarily in gastric parietal cells. Nursing implications
-Asses for epigastric or abd pain with occult blood in stool. -Administer with meals or immediately there after
Side effects
CNS: confusion, dizziness, drowsiness.
CV: arrhythmias.
Mirtazapine
(Remeron)...

References: 2. MEDICATION REFERENCE: SKIDMORE, L. (2011). NURSING DRUG REFERENCE. ST. LOUIS, MI. ELSEVIER. MOLBY
3
4. NURSING DIAGNOSES REFERENCE: GULNICK, M. AND MYERS, J. (2011). NURSING CARE PLANS, DIAGNOSES, INTERVENTIONS, AND OUTCOMES. CHICAGO, ILLINOIS. ELSEVIER
Vital Signs:
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