Careplan Essay

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XXXXXXXXXXXX Associate Degree Nursing Program Nursing Care Plan Student__XXXXX Instructor: XXXXXX Date: XXXXXX Patient Initials: XXX Age: 59 Rm. # Code Status:_Full DOA__Full DOSurg 10/3/2011 Admitting DX: Fx left femur Previous Medical History: Lt hip cyst removed 39 years ago. Vision impairment, corrected with glasses. Allergies and reactions (explain how the patient exhibits the allergy): NKDA Activity: Bedrest. With PT: Left toes touch weight bearing, rt foot full weight bearing. Diet/ Include any Fluid Restrictions (amount): Regular diet Vital Signs: (baseline) T-96.9, P-82, R- 22 O2 Sat 98% RA, 171/95 pain level 10. (am) T-97.6, P- 77, R-18 O2 Sat 96%, 166/76 _pain level 4. (PM) T-97.5, P-73, R-18 O2 Sat 98%,122/58 pain level 3. I&O last 24 hours: Oral__980ml IV:_1521.7 Output: 2250 I/O balance: + 251.7 Admit weight: 72.6kg Admit height: 177.8cm Today’s weight:_84.5kg. I asked the pt what he normally weighs & he stated about 180lbs or 81.8 kg. I think it admission weight was an error. IV: Type of solution_LR Rate__75ml/hr IV Site condition: Dry & Intact, date started: 03 Oct 2011 Equipment: IV pole, IV pump, O2 Sat monitor Treatments: Diagnostics and Results: (X-Rays, CTs, etc.) X-ray to Lt shoulder & Lt femur. Lt shoulder soft tissue injury and Lt femur fx. CT of Lt femur. Procedures and Results: Two blood transfusion of pack cells. One on 10/4 and one on 10/5. No reactions. |LAB TEST |RESULT |Normal Range |WHAT CAUSED CHANGE? |RELATE TO PATIENT’S ILLNESS/DIAGNOSIS | |WBC 10/3 |H14 |4.5-11 |Trauma caused ↑production of neutrophils resulting|Pt presented c fx lt femur caused

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