Student Name: Alejandro Medina Date: 10/22/19 Client’s Initials: J.R DOB: 01/28/1941 Admission Date: 12/09/2018 Age:78 Sex: M Race:Hispanic Religion: N/A DNR Advanced Directives: Activity: Allergies: Seafood, Polen Precautions: N/A Diet: R Admitting Diagnosis/Chief Complaint: Rehab after car accident ribs fracture and shoulder dislocation , High Blood Pressure Past/Present surgical procedures (dates): N/A Hx. of Present Illness: Pt involve in a car accident during hospitalization contract pneumonia. Meds prior to admission: 1. Lasix 5. Ginseng Caps 2. Keflex 6. 3. Pantoprazole 7. 4. Aspirin 8. Fortis College Nursing Care Plan Textbook Picture Client Picture Definition: Etiology: Predisposing Factors: Incidence: Pathophysiology: Signs & Symptoms: Diagnostic Tests: Treatment: MEDICATIONS: (TOPICAL, PO, IM, SQ, IV) Name/Dose Route/Frequency Safe/Range Mechanism of Action Indications Side Affects Nursing Considerations Why is client receiving this medication? Lasix Keflex Pantoprazole Aspirin Blood Cell Profile Norm. Values Date Date Date Chemistry Profile Norm. Values Date Date Date Hgb 12.0--16.0 Na+ 136--144 Hct 35.0--45.0 K+ 3.6--5.1 WBC 4.0--10.0 Cl 101--111 Platelets 140--350 CO2 22--32 RBC 3.80--5.00 Anion Gap 7--13 MCV 81--100 Glucose 80--126 MCH 28--32 Bun 8--20 MCHC 32.0--36.0 Creatinine 0.7--1.2 RDW 11.5--14.5 Bun/Creat 10--15 MPV 8.8--13.0 Ca++ 8.9--10.3 Neutrophils 40--75 Total Protein 6.1--8.0 Lymphocytes 20--50 Albumin 3.5--4.8 Monocytes 0.0--10.0 Globulin 1.6--3.2 Eosinophils 0.0--5.0 Alb/Glob .

1. Student Name: Alejandro Medina
Date: 10/22/19
Client’s Initials: J.R
DOB: 01/28/1941
Admission Date: 12/09/2018
Age:78
Sex: M
Race:Hispanic
Religion: N/A
DNR
Advanced Directives:
Activity:
Allergies: Seafood, Polen
Precautions: N/A
Diet: R
Admitting Diagnosis/Chief Complaint: Rehab after car accident
ribs fracture and shoulder dislocation , High Blood Pressure
Past/Present surgical procedures (dates): N/A
Hx. of Present Illness: Pt involve in a car accident during
hospitalization contract pneumonia.
Meds prior to admission:
1. Lasix
5. Ginseng Caps

2. 2. Keflex
6.
3. Pantoprazole
7.
4. Aspirin
8.
Fortis College Nursing Care Plan
Textbook Picture
Client Picture
Definition:
Etiology:

3. Predisposing Factors:
Incidence:
Pathophysiology:
Signs & Symptoms:
Diagnostic Tests:
Treatment:
MEDICATIONS: (TOPICAL, PO, IM, SQ, IV)
Name/Dose
Route/Frequency
Safe/Range
Mechanism of Action
Indications
Side Affects

4. Nursing Considerations
Why is client receiving this medication?
Lasix
Keflex
Pantoprazole
Aspirin

6. Blood Cell
Profile Norm. Values
Date
Date
Date
Chemistry

7. Profile Norm. Values
Date
Date
Date
Hgb 12.0--16.0
Na+ 136--144
Hct 35.0--45.0
K+ 3.6--5.1
WBC 4.0--10.0
Cl 101--111
Platelets 140--350
CO2 22--32

8. RBC 3.80--5.00
Anion Gap 7--13
MCV 81--100
Glucose 80--126
MCH 28--32
Bun 8--20
MCHC 32.0--36.0
Creatinine 0.7--1.2
RDW 11.5--14.5

9. Bun/Creat 10--15
MPV 8.8--13.0
Ca++ 8.9--10.3
Neutrophils 40--75
Total Protein 6.1--8.0
Lymphocytes 20--50
Albumin 3.5--4.8
Monocytes 0.0--10.0
Globulin 1.6--3.2

10. Eosinophils 0.0--5.0
Alb/Glob 1.5--2.5
Abs. Neutrophils
Bands
Segments
Coagulation Norm. Values
Date
Date

11. Date
Lipid Profile Norm. Values
Date
Date
Date
Ptt 23.2--36.4 sec
Total Chol. <200
Pt 11.5--15.0sec
Triglycerides <100
INR 2.--3.0
HDL >50
Bleeding Time
LDL <100

12. Cardiac Chem.
Date
Date
Date
Thyroid Function
Date
Date
Date
Total Ck 0--200
TSH (0.34—5.60)
Ck MB <7
Myo globulin 8-66
Hepatic
Date
Date
Date
Troponin I <0.5

13. Total Bili. (0.4-2.0)
Dir. Bili. (0.1-0.5)
Glucose Tol. Test
Date
Date
Date
Ind. Bili. (0.0-1.2)
HGB A1C (3.6-6.8)
Alk Phos (38-126)
AST (SGOT) (15-41)

14. ALT (SGPT) (14-54)
Anemia Eval.
Date
Date
Date
Amylase (36-128)
Arterial Blood Gas
Lipase ( 8-57)
PH (7.35-7.45)
Bile

15. O2 saturation (>90%)
PCO2 (35-45)
HCO3 (22-26)
PO2 (80-100)

16. Urinalysis Norm. Values
Date
Date
Date
Other Lab Results:
Color (straw or amber)
Appearance (clear to hazy)
Sp.Gravity (1.005-1.025)
PH (4.5-8.0)
Glucose (Negative)

17. Ketones (Ketones)
Other Lab Results:
Blood (Negative)
Protein (10-140mg/L)
Bilirubin
Urobilinogen (Negative 0-0.02)
Nitrite (Negative)
Leucocytes (Negative)
Other Lab Results:

18. RBC (0-3/hpf)
Casts (0/1pf)
WBC (0-4/hpf)
Crystals
1
1
1
RELATE THE CLINICAL SIGNIFICANCE OF YOUR
PATIENTS ABNORMAL LAB VALUES TO THE DISEASE

19. PROCESS YOUR PATIENT IS EXPERIENCING (If any)
Diagnostic Test & Results
Date:
Test Performed
Location
Results
X-Ray

20. MRI
Scans
Ultrasounds
Others

21. Date:
Patient Assessment
Mental/ Neuro
Loc pt oriented times 4
HEENT
Cardio
HR: 80bpm regular
BP: 140/100
Respiratory
RR:21
Lungs Sound heard all lobes crackles on both bases.
Peripheral Vas. System:
WNP
Cap Ref: <3sec
Abdomen / GI
Pt experiencing constipation
Musculoskeletal/Mobility:
Limited ROM due pt Pain
GU:

22. Endocrine:
Labs WNP
Integumentary:
WNP
Education
Nursing Diagnosis
1 Acute Pain Related To physical Injury (fracture ribs) as
Evidenced By the pt reports pain, guarding behavior and
expressive behavior like restlessness.
2 Risk for Ineffective Breathing Pattern risk Factors Include
pain musculoskeletal impairment evidenced by signs and
symptoms ribs fracture.
3 Activity intolerance related to generalized weakness
imbalance between oxygen supply and demand as evidenced by
pt reports fatigue, feeling weak and dyspnea ECG.

23. PLAN OF CARE ASSESSMENT:
Subjective Data (symptoms)
Objective Data (signs):
NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
Short Term:
Long Term:
PLANNING :
IMPLEMENTATION (NURSING
INTERVENTIONS/ACTIONS):
Date

24. Nursing Actions (Assess, Assist, Teach)
Rationale
EVALUATION OF GOALS:

25. REFERENCES:
PLAN OF CARE ASSESSMENT:
Subjective Data (symptoms)
Objective Data (signs):
NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
Short Term:
Long Term:
PLANNING :
IMPLEMENTATION (NURSING
INTERVENTIONS/ACTIONS):
Date
Nursing Actions (Assess, Assist, Teach)

26. Rationale
EVALUATION OF GOALS:
REFERENCES:

27. PLAN OF CARE ASSESSMENT:
Subjective Data (symptoms)
Objective Data (signs):
NURSING DIAGNOSIS (primary):
OUTCOME (GOALS):
Short Term:
Long Term:
PLANNING :
IMPLEMENTATION (NURSING
INTERVENTIONS/ACTIONS):
Date
Nursing Actions (Assess, Assist, Teach)
Rationale

28. EVALUATION OF GOALS:
REFERENCES:

29. 8
10
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