Select Page

lizmohammad
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