Care Plan

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Clinical Nursing Foundations N3632 Student name: Care Plan Date you had patient: 010/12/11 Clinical Instructor: Patient initials: TJ Room #: 4104 Gender: Male Age: 73 Admit date to hospital: 10/09/11 Medical diagnosis: COPD, respiratory and Renal problems, UTI Basic Health History: TJ is a 73-year-old male who was admitted because of a chief complaint of having urinary frequency and an increased shortness of breath over 1 day. He subsequently was admitted with increased respiratory difficulty, increasing dyspnea, and a burning sensation when he urinates. Pt has no known allergies and is full code status. Physical examination reveals that the patient has a BP of 128/84, pulse rate of 133, and respirations of 20. After he was given IV hydration, rocephin, and solo-medrol, BP continued at 144/77, heart rate 77, respirations 21, and 97% in 2L room air. Pt has a fall risk score of 35 and a braden score of 19, he also complains of SOB when attempting to ambulate around his room. Pt is on a full diet and has finished 100% of every meal brought to him so far. He also states that he has a family history of COPD. He has a history of high cholesterol, COPD, high blood pressure, and prostate issues. He has also had prostate surgery and another surgery for hernia repair. Pt use to smoke about 6 cigarettes a day and his labs show infected urine positive for nitrates, RBC and WBC clumping was also found in urine. Pt is divorced with no children, support system is not evident. Pathophysiology of admitting medical diagnosis and how the pathophysiology relates

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