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Assignment: Clustering & Prioritizing Data INSTRUCTIONS FOR…
Assignment: Clustering & Prioritizing Data
INSTRUCTIONS FOR ASSIGNMENT WINTER 2023
Nursing Care Plan Assignment Instructions
Assignment # 3 10% Final Grade
DUE WEEK 10- March 26
Case Study:
Anita Jones is a 60 year old who lives alone. Her husband died 3 years ago from prostate cancer. Anita is too tired to cook and she has joint pain that she states is “unbearable”. She states that some days she is so weak and tired she cannot get out of bed. She has lost 5 pounds in 2 months and has no appetite. On occasion she realized that she had been sitting in one position and just staring into space for prolonged periods. Her joints are sore and she is afraid to use them. She has a fear of the pain medication for her rheumatoid arthritis and refuses to take them as she believes that it is causing her to be forgetful. She is much more forgetful and is being investigated for Alzheimer’s disease. She is trying to ambulate more and forcing herself to eat small amount even when she doesn’t feel like eating, and she feels that “it doesn’t worth the effort”. She sleeps 6 hours per night and gets up frequently to go to the washroom. Her legs are edmeateous (swollen) and she has some bruising to her legs and back. She has no friends and she is not involved in any social activity. She has a 10 year history of hypertension and she sometimes feels very dizzy when she gets out of bed. She is steady on her feet and has no falls. She has blurred vision and wears glasses. Her admission diagnoses are Diabetes Mellitus Type 2 and Failure to Thrive.
History and Assessment
Anita 60 year-old female admitted to the hospital with medical diagnoses of Diabetes Mellitus Type 2 and Failure to Thrive (FTT). She also has hypothyroidism, rheumatoid arthritis(RA) and Depression (multimorbidity). Past surgical history: appendectomy in 1990; Hysterectomy in 1993; Lumpectomy 1991, MI in 1990
History of MRSA and VRE from previous admission.
Language: English and French
Braden Score is 10
Anita lives by herself in her own home and has no mortgage. Her symptoms are severe fatigue, frequent urinary output, guilt, poor memory and concentration
Weakness joint deformities and pain from the RA.
Previously a smoker x6 years but quit smoking over 25 years ago.
Height is 5 feet 3 inches. Weight 136 pounds.
Her hair looks dull on inspection and not combed.
Reddened areas to the coccyx but no open area to skin
Skin pale cool and dry to touch; her mucous membranes in her mouth are dry as well.
Capillary refill to nail beds is <2 seconds
Patient states she is very sensitive to the cold.
Medications: Ramipril 10mg PO QD, Levothyroxine 75mcg PO QD, Metformin 1000mg PO BID, Tylenol 100mg PO every 6hours PRN
Medication Allergic: penicillin; Sulpha
Food Allergy: Peanut
Breathing normal no use of accessory muscle, no nasal flaring, no cyanosis
Respiratory rate = 20 Spo2= 93% on room air
BP 140/70, P 77, Temp. 36.
Breath sounds normal no wheezing or crackles, no shortness of breath
Heart sounds are regular, Normal S1 and S2 sound, No jugular vein distention
Urine concentrated and foul smelling
Redness to coccyx but no open area
Patient states she has had no appetite for the last month
Bowel movements occur once every 3 days after she uses a laxative.
Abdomen is round and soft, non-tender with active bowel sounds in all four quadrants.
Chest X-Ray and CT March. 12
Blood work completed March 13th results:
WBC 7.5 Normal (4.5 to 11.0 × 109/L
Hemoglobin- 120 Normal 120 g/L to 160 g/L.
Platelet- 200 Normal (130-380 × 109/L)
Na-Sodium- 135 Normal 136-146 mmol/L
K+-Potassium- 3.5 Normal 3.5-5.1
Creatinine- 90 Normal 53 - 115 µmol/L
Glucose Fasting- 10 Normal 4.0 to 7.0 millimoles/L
Nursing Care Plan Part 1 Template 10%
Data Collection
Data Clustering
Prioritizing
1. Patient information and assessment data collection
Review and collect the assessment data about your client in the case study.
Date of Admission
Date of Assessment
Gender Identification
Allergies
Code Status
Religion
Admitting Diagnosis
Past Medical History (diagnosis and date of diagnosis if possible)
Past Surgical History (diagnosis and date of diagnosis if possible)
Medication Dose Route Frequency Reason YOUR patient is taking
Vital Signs
Temp
HR
BP
RR
O2Sat on R/A or amount of O2
Pain
O = Onset
P = Palliation / Provocation
Q = Quality/Quantity
R = Radiation / Region
S = Associated S&S
T = Timing
U = Understanding
Last Pain Medication?
Effect?
Sleep & Rest
Sleeping patters (#h/d)
Naps
Use of sedation
Feeling rested?
Mobility
Gait, balance
Independently ambulatory
W/C, Walker, Cane, Crutches
Bed ridden
Level of assistance required for movement (transferring, getting out of bed, walking, eating)
Neurological
Level of Consciousness
Orientation
Mental Status
GCS Number
Communication
Vision
Hearing
Cardiovascular
Radial pulse - rate, rhythm, strength
Apical pulse - rate, rhythm
Heart valve characteristics
Capillary Refill
Peripheral Pulses X 4
BP
Edema - description, extent, pitting or non-pitting
Respiratory
Respirations - Rate, Rhythm, Depth,
Characteristics, Adventitious Sounds
Cough (productive or non-productive)
Secretions
Suction Requirement
O2 Saturation
Oxygen Therapy
Gastrointestinal
Abdomen shape, Scars, Lesions
Bowel sounds
Abdominal palpation
BM - last one, usual bowel patterns
Bristol bowel movement description
Continent/incontinent
Height
Weight
BMI
Diet
Amount consumed
Ability to eat
Genitourinary
Continent/incontinent
Catheter
Condition of Perineal Skin
Discharge/odor
Urine Assessment - characteristics, amount
Musculoskeletal
Upper body strength
Lower body strength
ROM
Contractures
Integumentary
Colour
Temperature
Skin Hydration
Skin Texture
Elasticity
Skin Turgor
Lesions
Wounds
Scars
Braden scale
Psycho-social (SELFACNG)
S - Self-Esteem: pertaining to hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient's self-esteem, Sense of self, in relation to the world, Sense of meaning and purpose, Value base, Evidence of Emotional Distress, Grief Issues
E - Energy Level: Patient's with psychological problems often have an alteration in level of activity.
L - Lifestyle: Living arrangements, significant relationships, occupation, hobbies or lack of interest in leisure activities, education, and any other data that provides information about the patient's personal situation.
F - Family System: contact and support from family members or significant others, family stressors, crisis events, and usual coping skills.
A - Affect: mood or emotional feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms.
C - Culture: refers to all cultural, racial, or anthropological variables that influence one's lifestyle and mental health, may refer to issues of homelessness, religious and spiritual preferences, if any. Discuss any related food needs and other areas of impact spirituality will have on their health status. I - Interests: Hobbies and other activities enjoyed
N - Needs: As expressed by the patient
G - Goals: As expressed by the patient
Lab Values & Diagnostic Tests
Date of lab work
Normal value
Tubes Insitu
IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains
(IV site, solution, rate)
Safety
Falls Risk
safety Measures - call bells, bed rails, seatbelts, lap tray
Psychological Security
Morse Fall Risk
List Your 4 top Priorities with Data
Priority No. #1
Priority No. #2
Priority No. #3
Priority No. #4
