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Summary

NCP final medical surgical. Professor V....

Description

Nursing Care Plan

Med/Surg

Taylor Gaia

Student name

Date 7/27/2017 Demographics

Room #

225B

Code status

Full code

Age

58

Admitte d

7/26/2 017

Gender

Male

Allergies

NKA

Diet

Regular

Activity

Bedridden

Chief Complaint Pain in left leg after motor vehicle accident (MVA) Primary Diagnosis on Admission Left transverse femur fracture Primary problem on day of care (if different than diagnosis) Severe pain r/t left transverse femur fracture Medical History Diabetes mellitus type II, pressure ulcer stage 2 coccyx (resolved) Surgical History None Admission summary (HPI) Verbatim Patient is a 58-year-old male who was transferred from the ED after suffering a closed fracture of the left femur. Patient developed fracture motor vehicle accident. Patient states pain as “excruciating”. He has a history of type II diabetes mellitus. X-ray shows a transverse fracture of the left femur. Course of action is to apply external fixation. Relevant BCFs Primary Language

English Family System:

Patient lives with his wife of 35 years and two daughters. His daughter are ages 20 and 22. Patient has a brother who lives in New York, and states to only see him around Thanksgiving and Christmas. He claims to be very involved in his daughter’s lives and sees them as “the greatest thing I’ve ever done in my life”. Religion

CARE PLAN TWO

2

Faith/Denomination Christian Socio-Cultural Factors

The patient is Caucasian. He was born in Brooklyn, New York where he remained until meeting his wife in his early twenties. After he was married, he and his wife moved to California in order to be closer to wife’s family. He works in real estate for a company named CBRE, primarily working with marketing analysis. Patient reports his job to be a “desk job”. Wife is an elementary school teacher. Both of his children are currently attending college and he expresses that it is difficult to keep up with the expenses. Environmental Factors

The patient lives in a two-story home in Murrieta, California. He performs all his ADL’s without assistance. The patient states to have smoked from age 20-32, about 1 pack a day, quit at age 32 and never smoked cigarettes since. Patient claims to not drink alcohol. Patient states to love tennis and plays twice every week for an adult team. When discussing his concerns for current hospital stay, patient states, “I am so bored here… I can’t even imagine what I won’t be able to do at home…I am sad that I cannot play my tennis anymore for a while…it’s depressing to think of these next few months”. Erikson’s Developmental Stage

Patient is in the generativity vs. stagnation stage of development. He appears to be happy and settled down in his relationship with his wife, and started a family that he is very proud of. He states “I really love my job and feel like I am important for the company to function… I’m one of the most longstanding and loyal workers there”. Patterns of Living at home

Patient describes his work days (Monday-Friday) as “sitting on a chair all day long doing lots of work”. Patient states he tries to work around the house on the weekends and whenever he can to help out his wife. He used to pick of their children from school when they were younger, but stopped since they began college. During the summers, they try to spend time outdoors a lot by going to the beach and their vacation home in Big Bear, California. Healthcare Insurance

Blue Anthem HMO

Vital Signs Temp P RR BP O2 sat Pain

0800 36.8C 88 20 142/69 98 9/10

1200 36.4C 86 18 137/63 97 6/10

1600 N/A N/A N/A N/A N/A N/A

CARE PLAN TWO Time 1145

3

Blood Glucose

Dose/Route

178

Site

1 unit insulin regular, subq

Lower left quadrant abdomen

Assessment Ht/Wt Behavior HEENT Neurological Cardiovascular Respiratory GI GU Musculoskeletal

Skin

Pain IV Site Focused Assessment

82kg, 182.8cm Cooperative, participative, facial grimacing, appropriate behavior Head is symmetrical, no complaints of H/A, no changes in vision, no nose or ear problems noted, no soreness of the throat. PERRLA, A&Ox4 NSR, S1 and S2 sounds present RRR, bilateral peripheral pulses 2+, cap refill...