Nursing Care Plan Presentation
Nursing Care Plan Presentation
***USE THIS SCENARIO AND THE RUBRIC TO WRITE A GOOD AND BEAUTIFUL POWER POINT****
65 YO W.F Catholic Full code resides town house in SE Washington
Presented with cough for the past 4 days.
Past med hx: HTN, Systolic heart Failure, Chronic Renal Failure, Pulmonary Embolism, GERD, Breast
Cancer, dilated cardiomyopathy
Past Surgical Hx: Rt Mastectomy
Allergies: Sulfa, Robittusin
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Home Meds: Warfarin, Pravachol, Lasix, ECASA, Ferrous sulfate,
Physical Exam:
Neuro: Alert, oriented to person, place, time. Clear speech. Anxious
CVS: heart s1 s2 no murmur, HR 116 regular BP 110/60 cap refill < 2 seconds, no peripheral
Edema. Saline lock line left hand
Resp: lungs scattered rhonchi throughout with crackles bibasilar. Cough productive white,
thick, unlabored resp, RR 22. Pulse oximeter 94% on oxygen 2l/min by nasal cannula
GI: Bowel sounds-normoactive , Abd soft, non-tender. Good oral intake, no BM
GU: Voiding freely
Muscskel: ambulatory, steady gait
Skin: No bruises, rashes. No skin breakdown
Admitting diagnosis: Acute Kidney Injury, Acute Bronchitis,
Hospital Medications: Duoneb, Solumedrol IV, Folic Acid, Ferrous sulfate, ECASA, warfarin,
Zofran, Azithromycin
BMP: Glucose 121, Na 137, Cl 98, K 2.8, HCO3 23, BUN 29, Creat 2.06
BNP: 144
CBC: WBC 15.1, Hgb 15.1, Hct, 30.3, Plat 265 INR – 2.7
Diagnostic Test:
EKG: Right Bundle Branch Block with acute T wave Changes
Chest Xray- No acute disease
Echocardiogram- ejection fraction 26%
Ct scan chest with contrast – mild atelectasis , no infiltrate
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