General Appearance/Mental State: Cardiovascular System: Male, 76 years old. Grey hair cut very short Diagnosed with hypertension and and balding. Blue eyes. Pleasant demeanour hyperlipidemia and smiles often. Rarely makes eye contact. BP: 120/82 lying flat taken on left arm Usually dressed in button down shirts and Radial pulse 64 weak and irregular jeans. Slouches in wheelchair and keeps head Apical pulse 64 strong and irregular down. Constantly fidgeting. Keeps right arm S1 & S2 heart sounds heard at all flexed at the elbow and held close to the cardiac sites with no additional sounds abdomen. Limited facial expressions but looks relaxed. Cooperative with care. Understands Heart sounds are muffled speech but is unable to respond verbally. Nods No edema noted in peripheral or shakes his head to answer yes or no extremities, all extremities are pink and questions. Unable to determine orientation. warm to touch GCS of 11 and suffers from dementia. Radial, ulnar, carotid, brachial pulses palpable Capillary refill <2 seconds No cyanosis noted in nail beds or extremities Respiratory System: Gastrointestinal System: Diagnosed with Chronic Obstructive Bowel sounds in all 4 quadrants Pulmonary Disease Umbilical hernia with protrusion mid 14 respirations per minute shallow and abdomen unlaboured Has bowel incontinence and wears a SPO2 of 92% on room air large brief Decreased air entry Often constipated but usually relieved with the use of suppository Lung sounds clear in upper lobes bilaterally. Unable to assess lung Poor fluid intake approximately 500ml sounds in right middle and left and per shift right lower lobes bilaterally due to Client eats well, usually >75% of client not breathing through his mouth meals Symmetrical chest expansion Appears hydrated, no tenting noted, Occasional productive cough with mucous membranes and lips pink and clear viscous mucous, usually moist approximately dime sized Abdominal distension but soft on palpation BMI is 21.56 (healthy weight)
General Appearance/Mental State: Male, 76 years old. Grey hair cut very short and balding. Blue eyes. Pleasant demeanour and smiles often. Rarely makes eye contact. Usually dressed in button down shirts and jeans. Slouches in wheelchair and keeps head down. Constantly fidgeting. Keeps right arm flexed at the elbow and held close to the abdomen. Limited facial expressions but looks relaxed. Cooperative with care. Understands speech but is unable to respond verbally. Nods or shakes his head to answer yes or no questions. Unable to determine orientation. GCS of 11 and suffers from dementia. Cardiovascular System: Diagnosed with hypertension and hyperlipidemia BP: 120/82 lying flat taken on left arm Radial pulse 64 weak and irregular Apical pulse 64 strong and irregular S1 & S2 heart sounds heard at all cardiac sites with no additional sounds Heart sounds are muffled No edema noted in peripheral extremities, all extremities are pink and warm to touch Radial, ulnar, carotid, brachial pulses palpable Capillary refill <2 seconds No cyanosis noted in nail beds or extremities Respiratory System: Diagnosed with Chronic Obstructive Pulmonary Disease 14 respirations per minute shallow and unlaboured SPO2 of 92% on room air Decreased air entry Lung sounds clear in upper lobes bilaterally. Unable to assess lung sounds in right middle and left and right lower lobes bilaterally due to client not breathing through his mouth Symmetrical chest expansion Occasional productive cough with clear viscous mucous, usually approximately dime sized Gastrointestinal System: Bowel sounds in all 4 quadrants Umbilical hernia with protrusion mid abdomen Has bowel incontinence and wears a large brief Often constipated but usually relieved with the use of suppository Poor fluid intake approximately 500ml per shift Client eats well, usually >75% of meals Appears hydrated, no tenting noted, mucous membranes and lips pink and moist Abdominal distension but soft on palpation BMI is 21.56 (healthy weight)
nursing_research_care_plan_3.docx