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NSG 300cc Care Plan
NSG 300cc Care Plan
Clincial Site: Suntree Adult Day Center Client Identifier: J.G. Age: 79
Assessment Data
Subjective Data: Patient stated he felt no pain. J.G. was very cooperative, as he shared family stories and old memories while being assessed.
Patient stated, “Do whatever you need, when you pull on my ear it reminds me of my Greek mother that tugged on my ears everytime I did
something I knew I was not supposed to.” He laughed continuously throughout the assessment.
VS: T : 97.8 F Labs: Although the client does not have any labs Diagnostics: Although the client does not have any
in his chart, the labs I would recommend diagnostics in his chart, I would recommend:
BP: 146/81 mmHg
include:
- Brain imaging: standard imaging, like an MRI or
HR: 70
- Psychometric testing: this test is a CT, are primarily used to rule out other
RR: 14 intended to diagnose all dementias, as it conditions that may cause symptoms similar to
O2 Sat: 94% on RA measures an individual’s mental Alzheimer’s disease (Alzheimer’s Association
capabilites and behavioural styles. I 2019). J. G. would benefit from brain imaging
No pain noted. Scoring a recommend this lab because J. G.’s because in some circumstances, health care
0 on the Wong-Baker faces
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pain rating scale. condition will continue to worsen, providers may use this as a tool to find out if the
therefore his caregivers will be well individual ahs high levels of beta-amyloid, which
informed (Alzheimer’s Association as stated before has toxic affects on brain cells.
2019b).
- Vitamin B12: This would be a routinely
test, that will help identify cognitive
imparments. Due to him being diagnosed
with two diseases resembling cell
degeneration, this would be an important
test for him to take routinely
(Alzheimer’s Association 2019).
Assessment: Orders:
Patient was alert x1, to person. Patient is responsive to questions but has - DNR
an attention span of approximately 10 minutes. - Regular Diet.
- Water and soap to wash skin tear.
Past medical history: Heart surgery (2001), Appendectomy,
- Approximate wound margin. Steri strip/nonadhering dressing
hypertension, hypothyroidism, and hypercholesterolemia.
for wounds.
Skin: - Pulse oximeter to obtain the Oxygen Saturation level as
needed (PRN).
- The individual’s skin is warm, dry, and intact. No lesions noted - Blood glucose test to rule out hypoglycemia or
on the exposed skin. hyperglycemia.
- The skin turgor is appropriate with no apparent tenting, - Activities of Daily Living (ADL): dependent on caregiver
bilaterally. - Bathing: 1 person assisst supervision
- Upon assessment, no upper body edema was noted bilaterally. - Hydration: drink 8-12oz fluids each day.
- The radial pulses are strong, equal and palpable bilaterally,
approximately 2+.
- Capillary refill is less than 2 seconds bilaterally on fingers and
toes.
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Head, Face, and Neck:
- The head is a normocephalic shape, face is symmetrical, and
neck is proportionate to the head and face; hair distribution is
normal.
- Temporal and carotid arteries are palpable bilaterally.
- The patient denied pain or tenderness on the maxillary and
frontal sinuses, bilaterally.
- After assessing TMJ, the client denies pain; no popping or
clicking noted bilaterally.
- Cranial nerve V, Trigeminal is intact. Although, sluggish
reaction to the cotton ball stimulus.
- Cranial nerve VII, Facial, is intact.
- CN XII, Hypoglossal, is intact.
- Lymph nodes are non-palpable and non-tender bilaterally.
- Trachea is midline.
Eyes:
- The eyes are symmetrical, conjunctiva is pink, sclera is white,
and no drainage or jaundice were noted bilaterally.
- For PERRLA assessment, pupils are equal and round bilaterally,
pupils are sluggish reactive to light ( both direct and consensual)
and accommodation showed sluggish pupil constriction, and
dilation bilaterally. Convergence is noted. Pupil size is noted at
approximately 3 mm bilaterally.
Ears:
- External ears are intact and symmetrical. The color is consistent
with his exposed skin, and the pinna and tragus are nontender
and moveable, bilaterally.
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Nose, Mouth, Throat:
- The nose is midline. Nares are symmetrical and patent
bilaterally.
- Tongue is pink, moist, and without lesions. The buccal mucosa
is pink, moist, and without lesions bilaterally. He has an upper
denture, however, dentition is intact.
- Uvula rises with pronation; CN XII, Glossopharyngeal is intact.
Thorax:
- The client is sitting upright and respirations are regular, even,
and non-labored.
- The rise/fall of posterior chest is symmetrical.
- Bilateral breath sounds are clear to auscultation throughout
posterior chest in all lobes. Good inspiratory effort, no
adventitious sounds noted.
- No carotid bruits auscultated bilaterally.
- Bilateral breath sounds are clear to auscultation throughout
anterior chest in all lobes. Good inspiratory effort, no
adventitious sounds noted.
- S1 and S2 heart sounds auscultated with regular rate and
rhythm; no S3 and S4 sounds or murmurs auscultated.
Extremities:
- There was no swelling, tenderness, redness or nodules noted in
the shoulder, elbow, wrist, knee, or ankle joints bilaterally.
Client denies pain with palpation. No spinal abnormalites noted.
- Client has equal range of motion in all joints, bilaterally.
Strength, with and without resistance is equal in the shoulder,
elbow, wrist, knee, and ankle bilaterally.
- No lower body edema was noted, bilaterally.
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- The posterior tibial and dorsalis pedis pulse sites were strong,
equal, and palpable bilaterally, approximately 2+.
- The capillary refill of the toes was sluggish and took
approximately 5 seconds to refill bilaterally.
Neurological:
- The barefoot and heel-to-toe gait is steady, and patient
ambulates independently.
- Negative Romberg test; no swaying noted.
- Deep tendon reflexes of brachioradialis and patellar reflex are
present bilaterally.
- Rapid Alternating Movements are noted and intact, bilaterally.
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Medications
ALLERGIES:
Sulfonamide
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and lipid panel
periodically during
therapy (Vallerand,
Sanoski, & Deglin,
2017).
Tylenol/Acetaminophen 1000mg PO Every 6 - Treat mild pain, fever. CNS: agitation, anxiety, 1. Assess the overall
hours/PRN - Inhibits the synthesis of headache health status and
prostaglandins that may serve CV: hypertension, hypotension alcohol usage before
as mediators of pain and fever, GI: hepatotoxicity, constipation, administering.
primarily the CNS. increased liver enzymes, nausea, 2. Patients who are
vomiting malnourished or
chronically abuse
alcohol are at higher
risk of developing
hepatotoxicity.
(Vallerand, Sanoski, &
Deglin, 2017).
Tylenol/Acetaminophen 500mg PO Every 6 - Treat mild pain, fever. CNS: agitation, anxiety, 1. Assess the overall
hours/PRN - Inhibits the synthesis of headache health status and
prostaglandins that may serve CV: hypertension, hypotension alcohol usage before
as mediators of pain and fever, GI: hepatotoxicity, constipation, administering.
primarily the CNS. increased liver enzymes, nausea, 2. Patients who are
vomiting malnourished or
chronically abuse
alcohol are at higher
risk of developing
hepatotoxicity.
(Vallerand, Sanoski, &
Deglin, 2017).
Imodium/Loperamide Per label PO Per label - Relief of acute diarrhea. CNS: drowsiness, dizziness 1. Assess the frequency
- inhibits peristalis and GI: constipation, abdominal and consistency of
prolongs transit time by a direct pain, distention/discomfort, stools and bowel sounds
effect on nerves in the intestinal nausea. proior to and during
muscle wall. Reduces fecal therapy.
volume and increases viscosity. 2. Assess fluid and
electrolyte balance and
skin turgor for
dehydration (Vallerand,
Sanoski, & Deglin,
2017).
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Ibuprofen 400mg PO Per label - Decrease pain, inflammation, CNS: headache, dizziness, 1. Assess for signs and
and fever. drowsiness, intraventricular symptoms of GI
- Inhibits prostaglandin hemorrhage. bleeding, renal failure,
synthesis. EENT: amblyopia, blurred and hepatic impairment.
vision, tinnitus. 2. Assess patient for
CV: heart failure, edema, skin rash frequently
hypertension. during therapy.
GI: GI bleeding, hepatitis, Discontinue after first
constipation, dyspepsia, nausea. sign of rash (Vallerand,
Sanoski, & Deglin,
2017).
Hydrocortisone Cream 1% Per label Topical Per label - Suppress normal immune DERM: allergic contact 1. Assess affected skin
system response and dermatitis, atrophy, burning, before and daily during
inflammation. dryness, edema, hypersensitivity therapy. Note
- Suppression of dermatologic reactions, irritation, secondary inflammation and
inflammation and immune infection. pruritus.
processes. 2. May cause increased
serum and urine glucose
concentration if
significant absorption
occurs (Vallerand,
Sanoski, & Deglin,
2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Anxiety
Anxiety, related to cognitive impairment, as evidence by constant pacing and agitation.
- Client will have posture, facial - Client will demonstrate - Recognize awareness of the - Since a cause of anxiety cannot - Caregivers and student
expressions, gestures, and increased external focus by the patient’s anxiety. always be identified, the patient nurses were with J.G.
activity levels that reflect end of the day. - Use presence, touch, may feel as though the feelings throughout the entire day,
decreased distress throughout his - Client will remain distracted verbalization, and demeanor to being experienced are ensuringt that he did not
day at Suntree day center. with caregivers, keeping him remind patient that they are not counterfeit. Acknowledgment of place himself in an
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from wandering off throughout alone and to encourage the patient’s feelings validates untentional dangerous
his stay at Suntree day center. expression or clarification of the feelings and communicates situation due to his anxiety
needs, concerns, and questions. acceptance of those feelings. and wandering.
- Interact with patient in a - Being supportive and - Caregivers and student
peaceful manner. approachable promotes nurses kept J.G. distracted all
communication. day, asking him stories and
- The nurse or health care for help to ensure that they
provider can transmit his or her knew were he was the entire
own anxiety to the time.
hypersensitive patient. The - J.G. had several peaceful
patient’s feeling of stability interactions with the nursing
increases in a calm and non- students, as he sang with
threatening environment them and shared fun personal
(Wayne, 2019a). stories while I assessed him.
References
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Alzheimer’s Association (2019b). Medical tests. Retrieved from https://www.alz.org/alzheimers-dementia/diagnosis/medical_tests.
disease/symptoms-causes/syc-20350447.
20352013.
pathophysiology.
Wayne, G. (2019a). Anxiety – nursing diagnosis & care plan. Retrieved from https://nurseslabs.com/anxiety/.
Wayne G. (2019b). Chronic confusion care plan and nursing diagnosis guide. Retrieved from https://nurseslabs.com/chronic-
confusion/.
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