care plan 1

Hi! Please follow the following instructions on how to complete this care plan. Attach you find the template to fill it out and an example of how it should look as well (obviously not the same information). Make sure to include all APA citation and references on its own page at the end. Make it sound complete and detailed.

Age: 93 yr old, gender, male, weight: 69 kg, bmi: 28.72, height: 155 cm, religion: catholic, language: english, marital status: make it up, occupation: make it up, health insurance: make it up, current work status, highest grade completed : make it up.

Alcohol/Smoking/Drug use/Sexual and Reproductive health: Patient denies alcohol, electronic vaping, substance use, and tobacco use. Support system: family lives in

but is aware. Siblings: N/A.

Name of significant other/primary caregiver: make it up.

Current medical diagnosis: Calcific tendinitis in the right elbow

Diagnostic Data and Results: Right elbow x-ray read impression:no evidence of acute fracture or traumatic malalignment. Extensive demineralization a small calcification along the lateral joint line that could represent combination of calcific tendinopathy in CPPD arthropathy. Right hip with pelvis x-ray read impression: no evidence of acute fracture or tramuatic malalignment. 

Surgical procedures (current and past): arthroplasty replacement total knee level 5 (right knee) in 12/19/2017, appendectomy, cataract, and shoulder. 

Past Health History:A-fibrilation, chronic anticoagulation, Hypertension, hypercholesterolemia, meningioma, osteoarthritis of glenohumeral joint, and right shoulder pain(explain how its ongoing).

History of Present Illness: 93 year old male with a paroxysmal a fib on Eliquis, dyslipidemia, permanent pacemaker, demetia. chronic right shoulder pain, gait disturbance, BPH who arrived via rescue for evaluation of a fall. History is taken from a wife at bedside as patient is pleasantly confused. Patient states that he fell as he was standing up. Wife denies any head trau,a that patient sustained. In the ER, he complains a lot of right elbow pain and is unable to move the right upper extremeity.( Make sure if the pt stated it, put it in quotations) Paraphrase this. 

Review of Systems: follow the example as to things to include. this is subjective, must be what the pt explain or denies. Make it up in accordance to the pt’s info. MAKE SURE IT CORRELATES AND MAKES SENSE. THINGS TO INCLUDE HOWEVER: 

for musculoskeltal: reports right shoulder pain, fall at home. Integumentary: bleeding lacerations to the right upper extremeity. Neurologic: memory loss. Psychitaric: confusion and agitated at night. 

Health Assessment: make sure to follow the example when completing it for this one. Make sure these key points are listed: Skin: skin is warm, right elbow laceration, right distal wrist laceration with bleeding noted. Neuro: poor judgment and insight, appropriate mood and affect. 

For patho, make sure to use APA citations edition 7 and include in text citations

Baseline and current vital signs/Frequency: T: 37 C, HR 90, RR:15, BP:140/117, SPO2:99%, AND Taken every 4 hours (Q4)

Allergies/Side effects: NKA

Diet with rationale : a regular diet, explain why and how they are able to eat their full amount of nutrients with no problems. describe with a good rational.

Activity order: make it up

Limitations/prosthetic devices: make it up, pt is on fall risk

Use the following 4 data results for data:

Potassium: 3.9 mmol/L

C02 in blood: 23 mmol/L

Troponin I (Quant): 0.04 ng/mL.

BUN on Blood: 35 mg/dL

For solution bags: make it up. have at least 1.

For meds, use these: atorvastatin (Lipitor) 80 mg tablet oral daily, docusate sodium (colace) 100 mg capsule oral BID, doxazosin (cardura) 4 mg tablet oral BID, famotidine (pepcid) 20 mg tablet oral daily, haloperidol lactate (Haldol) 5 mg/mL vial 1 mg 0.2 mL, IV push, once. Make sure when describing rationales and nursing implications to cite and include the citation on the side and at the last page for references.

For theories: use 2, may be the same ones as on the example.

For nursing diagnosis, must be a part of NANDA 1 nursing diagnosis. MUST BE NANDA, must be a complete nursing diagnosis

When completing the assessment data, the goals, and the interventions, subjective and objective data may be made up but it must make sense. Make sure you write the three nursing diagnosis and subjective and obejctive data that belong to it.

HOWEVER, YOU ONLY HAVE TO ELABORATE ON THE MOST IMPORTANT NURSING DIAGNOSIS which will be the first one on the list. Make sure it has one short term goal, one long term goal, and three interventions per goal. There must be a rationale for each intervention.  Make sure to include references at the end.

FOR ALL RATIONALES, MAKE SURE THERE IS IN TEXT CITATIONS AND REFERENCES AT THE END