KCupp Mini Care Plan 4 - mini care plan PDF

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Kaytlin Cupp – Mini Care Plan 4

Demographic Patient initial: Mr. C.S. Date of care: 10/19/20 Unit: Rehab Age: 89

Date of admission: 10/15/2020 Day of stay: 5 Gender: Male Race / ethnicity: Caucasian

Admitting diagnosis: Left subdural hematoma Co-morbidities: Dementia, hypothyroidism, CVA, Parkinson’s disease, coronary artery disease with pacemaker placement, atrial fibrillation, BPH Allergies: Sulfa and Macrobid Functional/residual history: Resides in a memory unit and requires assistance with ADLs and cognitive tasks – minimal assist bed transfer and moderate assist bed mobility, minimal assist chair transfer, ambulating four steps with a rolling walker moderate assist, moderate assist with ADLs.

Nursing Diagnosis #1: Ineffective cerebral tissue perfusion related to subdural hematoma as evidence by head CT from 10/15/2020 of left-sided subdural hematoma with mild mass effect on the left cerebral hemisphere. Assessment data to support diagnosis: confusion that is more significant than noted baseline for patient, lethargy, headache, decreased concentration, and mild mental status changes Short-term Goal: Patient will show no further worsening of deficits by end of shift Long-term Goal: Patient will exhibit improvements in mental status to return to his individualistic baselines by discharge Intervention #1: Assess VS and neuro exams q2h or as needed – note changes in pupil size and reactivity, or any changes in respiration rate, depth, or pattern Intervention #2: Continue to administer Keppra 500 PO b.i.d. as ordered until next seen by neuropsychology specialist Evaluation of Short-term Goal: Goal has been met as evidence by adequate cerebral perfusion maintained by end of shift at 1700 Evaluation of Long-term Goal: Goal currently unmet Evaluation of Intervention #1: Pt shows PERRLA with no changes noted in neurological or respiration status that would indicate brain stem compression Evaluation of Intervention #2: Patient tolerating medications and is scheduled to see neuropsychology specialist tomorrow, 10/20/2020

(Version:DMc1Jan2019)

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Nursing Diagnosis #2: Risk for injury related to general status and orientation of patient as evidence by inability to recall how obtained a subdural hematoma Assessment data to support diagnosis: A&O varies times 3 to 4, requires assistance with ADLs and ambulation; difficulty finding words during a conversation; poor short-term memory; forgetting details of personal history Short-term Goal: Patient will maintain full control of bowel and bladder throughout shift Long-term Goal: The use of restraints will be avoided during patient’s stay. Intervention #1: Routinely assess client for dehydration and potential urinary tract infection that could worsen level of confusion and place patient even more at risk of injury Intervention #2: Contact significant other or other family members to be with patient to prevent him from falling. Evaluation of Short-term Goal: Patient was able to maintain control of bowel and bladder throughout shift, pressing call light to alert staff when he needed to void Evaluation of Long-term Goal: Goal partially unmet – thus far, patient has been easily maintained without the use of restraints, which are invasive and could potentially lead to injuries. Evaluation of Intervention #1: No changes related to infection or dehydration noted Evaluation of Intervention #2: Patient seemed to have been confused when he stated that his wife was still alive – currently attempting to get ahold of any other living family members.

(Version:DMc1Jan2019)

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