[Solved]: Writing Nursing Care Plan: Clinical Case Situation:…

Writing Nursing Care Plan: Clinical Case Situation: Lila Smith, 70-year-old female, admitted for cough and SOB. Patient stated “I am not feeling good for over 2 weeks. I am tired, I can’t get-rid of this cough, keeping me up all night”. Patient has been taking Robitussin and Tylenol with no relief. History of HTN, CAD, CHF. Current medications: Lopressor 50 mg daily, Digoxin 0.25 mg daily, Calcium 500 mg daily. LOC – awake, alert, oriented x 3, looks anxious, SOB, frequent cough with moderate amount of light yellowish sputum, and mild cyanosis around the lips. Skin: pink, warm, moist, no lesions, no edema, TPR 100.5, 78 irregular, 24, 160/90 LA, chest tightness and non-radiating precordial chest pain level 4/10, apical heart rate 110/irregular, S1 & S2 irregular, no murmur, bilateral scattered wheezes in lungs. Mark Brown, MD ordered: Tele monitoring, saline lock, blood and sputum culture, CBC, CMP, Chest X-ray, 12 Lead EKG, ABG, nebulizer treatment stat by RT, IV Ancef 1 gram every 8 hours after blood culture draw, Tylenol 2 tab every 4 hours for temp > 100, bed rest, may use bedside commode, low salt cardiac diet, encourage fluids by mouth, cardiology consult. Writing Nursing Care Plan from the above assessment data. Patient Initials: ___________ Age: ____________ Gender: ______ History of Present Illness (Reason for admission, admitting Diagnosis, surgery/procedures done): __ Past Medical/Surgical History: Subjective findings: Objective findings: General /VS: (including Pain assessment): Neuro: Musculoskeletal: Respiratory: Cardiac: IV Access: Fluids/Drips: GI: GU: Skin: Psychosocial/Family: Pertinent Labs/Radiology/other exams: Problem List (list patient’s problems/priority of needs using NANDA International Approved Nursing Diagnosis.1), 2),3), 4), 5), 6) Priority Nursing Diagnosis/patient’s problem (address 4 problem and writes the plan of care below): Care Plan: Problem # 1 Outcomes/Goals (what do you want to see happen): Short Term Goal: Long Term Goal: Interventions (List five interventions with the rationale for each intervention with evidence-based practice/reference) Evaluation (Show achievement of goal/outcome with nursing intervention): Medication List: (List the current medications of this patient and write the following information on 2-5 medications): ● Name of the drug with dose, route, frequency ● Drug classification ● Indication for this patient ● Action and side effects of this drug ● Nursing responsibilities with this medication administration