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Hi! Please follow the following instructions on how to complete this care plan. Attach you find the template to fill it out and an example of how it should look as well (obviously not the same information). Make sure to include all APA citation and references on its own page at the end. Make it sound complete and detailed. Age: 80, gender, male, weight:92.3 kg, bmi: 24.52, height: 194 cm, religion: catholic, language: english, marital status: make it up, occupation: make it up, health insurance:make it up, , current work status, highest grade completed : make it up. Alcohol/Smoking/ Drug use/Sexual and Reproductive health:Patient denies alcohol, electronic vaping, substance use, and tobacco use. Support system: family lives in but is aware. Siblings: N/A. Name of significant other/primary caregiver: make it up. Current medical diagnosis: Cellulitis on the left lower extremity. Diagnostic Data and Results: Foot LT Min 3 views XR, impression said: no definite acute bony erosion to confirm acute . Soft tissue swelling and small focus of soft tissue air at the ventral forefoot. chronic bony findings. Cardiovascular results: venous duplex LE bilateral: impression is there is no deep vein thrombosis bilaterally. Surgical procedures (current and past): appendectomy, CABG- coronary artery bypass graft, cholecystectomy, and prostatectomy. Past Health History:Diabetes mellitus and hypertension (explain how its ongoing). History of Present Illness: write a detailed history about this is an 80 year old male with history of diabetes prior osteomyelitis with toe amputation who comes from for medical care. Has been worsening lower extremity redness swelling wound dorsal aspect of the foot. No obvious drainage at this time but does report some in the past. He says sugars are well controlled at home and checks his blood sugars 3-4 times a day. (make sure when you state a pt’s statement, put it in quotation marks. Review of Systems: follow the example as to things to include. this is subjective, must be what the pt explain or denies. Make it up in accordance to the pt’s info. MAKE SURE IT CORRELATES AND MAKES SENSE. Health Assessment: make sure to follow the example when completing it for this one. Make sure these key points are listed: for musculoskeletal: swollen foot, redness and swelling, 1 cm circular wound mid dorsal distal aspect. Otherwise than this, everything else is within normal limits. For patho, make sure to use APA citations edition 7 and include in text citations
Baseline and current vital signs/Frequency: T: 36.8 C, HR 76, RR:20, BP:130/68, SPO2:99%, AND Taken every 4 hours (Q4)
Allergies/Side effects: NKA
Diet with rationale : a regular diet, explain why and how they are able to eat their full amount of nutrients with no problems. describe with a good rational. Activity order: make it up Limitations/prosthetic devices: make it up Use the following 4 data results for data: WBC: 10.39 K/uL
Platelet count: 344 K/uL
Hgb/Hct: 9.7 g/dL and 30.2% low. Sodium on Blood: 137 mmol/L
For solution bags: make it up. have at least 1. For meds, use these: atorvastatin 500 mg oral tablet 1 orally daily, benzapril 5 mg oral tablet once daily, hydrochlorothiazide 25 mg oral tablet 25 mg orally daily, and metoprolol succinate ER 25 mg oral tablet once daily. Make sure when describing rationales and nursing implication to cite and include the citation on the side and at the last page for references. For theorys: use 2, may be the same ones as on the example. For nursing diagnosis, must be a part of NANDA 1 nursing diagnosis. When completing the assessment data, the goals, and the interventions, subjective and objective data may be made up but it must make sense. Make sure you write the three nursing diagnosis and subjective and obejctive data that belong to it. HOWEVER, YOU ONLY HAVE TO ELABORATE ON THE MOST IMPORTANT NURSING DIAGNOSIS. Make sure it has one short term goal, one long term goal, and three interventions per goal. Make sure to include references at the end. Discharge plan: make it up
Make sure to include a genogram of at least the past 2 generations. Make it up but it must make sense!
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