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Mock Care Plan Assignment Instructions Each student selects a different Case Study and notifies the instructor via email on your selection. Instructor approval is required before you begin this assignment. Students are to download and complete the Care Plan using the Care Plan Grid. Students are to create a care plan using the selected and approved case study. The case study provides the students with a diagnosis to begin the care plan. Students are to use their critical thinking skills and add medical/nursing information to the care plan matching and aligning with the primary diagnosis.
Use your imagination in urging to complete your care plan. Students are to follow the Nursing Care Plan Rubric. Case Studies Patient X #1 Patient X is a 55 year old retired policeman who was constantly having cough during the last 2 weeks before he was brought to the hospital by his youngest daughter. Lately, he has been experiencing troubles in breathing. He described it as a difficulty in expiration during breathing. For this reason, he asked his youngest daughter who is living Just two blocks away from him to take him to the hospital.
Patient X admits to be a chronic smoker, consuming two packs per day and drinks alcoholic beverages secularly with his friends. After undergoing a thorough examination, his physician ordered a series of sputum tests and other lung tests. Chronic infection was detected in the lungs most probably due to smoking which irritates the bronchi and bronchioles. There was an obstruction of the airways which is responsible for Patient Ax’s difficulty in expiration. He was diagnosed with chronic obstructive pulmonary disease (COOP). Patient Y Patient Y is a 95 year old white male who was admitted to the Hospital.
Prior to being admitted to the hospital, Patient Y. Had been in excellent health. His troubles apparently began three weeks prior to being admitted. Patient Yes son found him lying on the floor confused, and soaked in urine. Patient Y was diagnosed as having an acute hemorrhagic cerebral vascular accident. Patient Y is the full-time caregiver for his daughter who has MS. Patient Y is alert but slow to respond due to receptive aphasia. Mr.. AD#3 Mr.. AD is a 72 year old male admitted to the ERE via ambulance with a diagnosis of OUT (Urinary Tract Infection). Temp. 02. 6 Rest. 24 Her 98 BP 198/78. He is confused, disoriented, and combative and his wife reports that this is a change. Mr.. AD believes e is in WI and must fight to survive. Mrs.. AD voiced that her husband is not like this, a gentle, caring man who cares for her and is her soul mate. Ms. AD cried uncontrollably because she does not know how she will survive with her own medical aliments. The ERE nurse removes the wife from the patient. The nurse returns to find the patient is cold, clammy, restless and trying to get out of bed. Patient voiced, “Take cover”.
His wife reports she was unable to fill the antibiotic prescription because of Atlanta restraints. Witt reports near NASDAQ NAS a nelsons AT HIND BP, Deadliest, and has had a left knee replacement 6 months ago. Wife states, “This is my entire fault, I did this”, I am a terrible wife”! MS. SST#4 Ms. SST arrived to the ERE with c/o pain in her left lower bad region especially after she eats, rectal bleeding, bloody stool, fevers, nausea and vomiting. Patient voiced that she is scheduled for a bowel resection because of her tuberculosis/difficulties.
Opt voiced she Just can’t take the pain anymore and has lost Bibb in 3 months. The patient’s current weight is bass. Opt voiced that she lives alone, not married, no family in town and supports herself, but would like some medication to stop her symptoms so she can return to work. Opt voiced a history of UT’, Coronary stints xx, Hysterectomy, and Breast Cancer. Patient voiced she is anxious and concerned over the condition; opt. Begins to cry and vomited ICC. Mr.. GAP#5 It is midmorning on the cardiac unit where you work, and you are getting a new patient. G. P. S a 60-year-old retired businessman, who is married and has 3 grown children. As you take his health history, he tells you that he began feeling changes in his heart rhythm about 10 days ago. He has hypertension(TN) and a 5-year history of angina pectoral. During the past week he has had frequent episodes of mid-chest discomfort. The chest pain has awakened him from sleep but does respond to nitroglycerin(NOT), which he has taken subliminally (SSL) about 8 to 10 times over the past week. During the week he has also experienced increased fatigue. He states, “l Just feel crappy all the time anymore. A cardiac categorization done several years ago revealed 50% Stetsons of the right coronary artery (RCA) and 50% Stetsons of the left anterior descending (LAD) coronary artery. He tells you that both his mother and father had coronary artery disease (CAD). His DXL Left inferior wall Myocardial Infarction. Mr.. C. W. #6 The wife of C. W. A 70-year-old man, brought him to the emergency department (DEED) at 0430 this morning. She told the DEED triage nurse that he had Had dysentery for the past 3 days and last night he had a lot of “dark and bright red” diarrhea.
When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. An endoscope showed a duodenal ulcer with adherent clot. The ulcer was categorized, and C. W. Was admitted to the medical intensive care unit (MICA) for treatment. Mrs.. Deed A 25 year old female reports to the Emergency Room because of sharp left sided chest pain and shortness of breath of one day duration. The patient was in excellent health until yesterday. She was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and deep breathing.
The pain has been progressively increasing in severity and she now has severe left shoulder pain. She complains of shortness of breath and is very apprehensive about dying. She denies any congou, Advert, sputum production or monoplanes. Seen Is currently on Dealt control pills. She has never been hospitalized except for labor and delivery. She reveals having a similar transitory minor episode of chest pain approximately one year ago hill she was vacationing in Michigan. She smokes one pack of cigarettes a day for the past eight years.
She considers herself a social drinker and c/o epileptic pain. Patient was diagnosed with Pulmonary Embolism. Mrs.. Butter #8 Mrs.. Butter had a 3-day history of progressive fevers, nausea, and vomiting. She presented to the emergency department at 2:30 a. M. , where she appeared to be moderately ill and dyspeptic. The examination was remarkable for crackles at her right lung base. The examination of her cardiac, abdominal, and neurological systems was unremarkable. A chest radiography showed a dense right lower lobe infiltrate. Bacterial pneumonia was diagnosed.
Mrs.. M. D. M. D. Is a 50-year-old woman who was notified of an abnormal screening mammogram. Diagnosis of infiltrating ducal carcinoma was made following a stereotypic needle biopsy off 1. 5 1. 5 CM elaborated mass at the 3:00 position in her left breast. M. D. Had a modified radical mastectomy with lymph node dissection. The sentinel lymph node and 11 of 16 lymph nodes were positive for tumor. Estrogen receptors and progesterone receptors were both positive. Further staging work-up was negative for distant metastasis. Her final staging was stage BOB. Y.
L is a 24-year-old Asian woman, arrives for her physician appointment.. Pat’s body mass index (IBM) is 25. Her father has type 2 diabetes mellitus (DMS), and both paternal grandparent’s had type 2 DMS. Patient c/o increased thirst, urinating and hunger. Patient consumes 90% of her meals in carbohydrate form. Physician has ordered a glucose tolerance test and is positive for Diabetes Mellitus. MS. C. W. C. W. Is a 36-year-old woman admitted 7 days ago for inflammatory bowel disease (BID) with small bowel obstruction (SOB). She underwent surgery 3 days after admission for a colostomy and elections.
She developed peritonitis and 4 days later turned to the operating room (OR) for an exploratory laboratory, which revealed another area of perforated bowel, generalized peritonitis, and a fistula tract to the abdominal surface. Another 12 inches of ileum were respected (total of 7 feet of ileum and feet of colon). The peritoneal cavity was irrigated with normal saline (NSA), and 3 drainage tubes were placed: a Jackson-Pratt UP) drain to bulb suction, a rubber catheter to irrigate the wound bed with NSA, and a sump drain to remove the irrigation. The initial JP drain remains in place.
A right civilians triple-lumen catheter was inserted. Mr.. M. M M. M. A 76-year-old retired school teacher and fell at home going to work and sustained a Ruling HIPS Fracture. I en patient was transferee to ten nonstop ambulance. The physician rushed the patient to surgery and underwent open reduction and internal fixation (ROOF) for a fracture of his right femur. Mr.. A. S. A. B. , a 40-year-old man, is admitted to your medical floor with a diagnosis of pleural effusion. He complains of (C/O) shortness of breath (SOB); pain in his chest; weakness; and a dry, irritating cough.
His chest x-ray (CAR) shows a large pleural effusion and pulmonary infiltrates in the right lower lobe (RL) consistent with ammonia. Mrs.. J. F. J. F. Is a 50-year-old married homemaker with a Dixon bacterial indoctrination. The most recent episodes were a Staphylococcus erasures infection of the material valve 16 months ago and a Streptococcus mutants infection of the aortic valve 1 month ago. During this latter hospitalizing, an EGG showed moderate aortic Stetsons, moderate aortic insufficiency, chronic uvular vegetation, and moderate left trial enlargement. Mr..
D. A D. A. Is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before signoras. He had fasting blood glucose records indicating values of 118-127 MGM/del, which were described to him as indicative of “borderline diabetes. ” He also remembered past episodes of nocturne associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb. “), but no further action was taken. Mr.. A. H. #16 A. H. S a 70-year-old retired construction worker who has experienced lumberjacks pain, nausea, and upset stomach for the past 6 months. He has a history of heart failure (HE), deep visceral pain, dyspnea, hypertension (TN), sleep apneas, and oppression. Patient is diagnosed with Abdominal Aortic Aneurysm. A. H. Has Just been admitted to the hospital for surgical repair of a 6. 2-CM abdominal aortic aneurysm (AAA) that is now causing him constant pain. Mr.. B. T. #17 B. T. , a 22-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pollen; anxiety appears to play a role in exacerbating his asthma attacks.
B. It’s wife drove him to the clinic when his wheezing was unresponsive to fluctuations (Violent) and opprobrium bromide (Adherent) inhalers, he was unable to lie down, and he began to use accessory muscles to breathe. Patient is diagnosis with Asthma. Mr.. C. E. C. E. , a 73-year-old married man and retired railroad engineer, visits his internist complaining: “Whenever I try to do anything, I get so out of breath I can’t go on. I think I’m Just getting older, but my wife told me I had to come see you about it. ” His resting Sass registers 83%.
He is sent to the local hospital for a chest x-ray (CAR) and arterial blood gases (Bags) to be drawn after resting 20 minutes room air. After obtaining the results, the physician calls C. E. And informs him that he has severe emphysema and must start on continuous oxygen (02) therapy. Mrs.. Cat #19 Mrs.. At Is a 3 2-year-010 woman Deluge Maltese to ten meals moor Witt a Lagoons of Acute Renal Failure and has complaints of (C/O) fatigue and dehydration. While taking her history, you discover that she has diabetes mellitus (DMS) and has been insulin dependent since the age of 8.
She has undergone hemophilia’s (HAD) for the past 3 years. Your initial assessment of the patient reveals a pale, thin, slightly drowsy woman. Her skin is warm and dry to touch with poor skin tutor, and her mucous membranes are dry. She tells you she has been nauseated for 2 days so she has not been eating or drinking. She reports severe diarrhea. Mr.. L. C. #20 L. C. Is a 78-year-old white man with a 4-year history of Parkinson disease (PDP). He is a retired engineer, is married, and lives with his wife in a small farming community.
He has 4 adult children who live close by. He is taking cardboard-leopard, paraglide, and amandine. L. C. Reports that overall he is doing “about the same” as he was at his last clinic visit 6 months ago. He reports that his tremor is about the same, his gait is perhaps a little more unsteady, and his fatigue is slightly more noticeable. L. C. Is also concerned about increased drooling. He also reports that his dyslectic events. The patient is diagnosed with Parkinson disease. Mrs.. D. W. D. W. Is a 23-year-old married woman with 3 children under 5 years old.
She came to her physician 2 years ago with vague complaints of (C/O) intermittent fatigue, Joint pain, low-grade fever, and unintentional weight loss. Her physician noted small patchy areas of vitriol and a scaly rash across her nose, cheeks, back, and chest at that time. D. W. Was subsequently diagnosed with systemic lupus erythrocyte’s (SLEW). Mrs.. G. C. G. C. Is a 78-year-old widow who relies on her late husband’s Social Security income for all her expenses. Over the past few years, G. C. Has eaten less and less meat because of her financial situation and the trouble of preparing a meal “Just for me. She also has medicines to buy for the treatment of hypertension (TN) and arthritis. Over the past 2 to 3 months, she has felt increasingly tired, despite sleeping well at night. When she goes to the senior clinic, the nurse practitioner orders blood work. The lab results indicated a diagnosis of anemia. Mr.. A. A # 23 You are the nurse on a medical unit taking care of a 40-year-old man, A. A. , who has been admitted with peptic ulcer disease (PUT) secondary to chronic alcoholism. He also has a history of “street” drug abuse. You enter A. A. ‘s room and find him having a generalized convulsive (tonic-clinic) seizure.