Name: Date: 4-13-12
Date of Care: 4-6-12
Nursing Care Plan
Client Initials: D.N Gender: M Age: 85 HT: 70in WT: 114lbs
Allergies: Eggs, morphine, peanuts
Admission Date: 2-1-12 Code Status: Full
Chief Complaint: Right hip pain, headaches.
Admitting Diagnosis: Right hip infection.
Recent Surgeries: 1-27-12, hardware removal from right hip.
Social History: Divorced. Has a frequent visitor who also lives at Hines, pt does not smoke or drink.
PMH: Reflux esophagitis, Barrett’s esophagus, compression fracture L2, T12, iron deficiency anemia, syncope, malignant neoplasm of prostate, osteoporosis, depressive disorder.
Diagnostic Tests (CXR, CT, etc.)
|Test |Date |Results |Reason(s) needed and if abnormal explain |
|Ultrasound |4-2-12 |Complete | |
| | | |Guidance for venous access |
|Portable chest |3-9-12 |Verified placement | |
| | | |Checked tip placement of R arm picc cath. |
| | | | |
| | | | |
| Item | Reason (explain specifically why it was ordered for this patient) |
|Diet Regular | |
| |Feeds self, no diabetes |
|Intake/Output urinal | |
| |Continent of stool, uses bedside commode |
|Vital Signs Blood Pressure | |
| |Patient is taking metoprolol |
|Activity Bed only | |
| |Patient is unable to ambulate |
|Accuchecks N/A | |
| |Patient is not diabetic |