Hi! Please follow the following instructions for this care plan:
This is a med surg care plan and attached you will find the template in which you have to answer in. and an example of There is also an example of what it should look like
This is the information to be used:
42 yrs old, male, came into the hospital due to moped accident. Denies alcohol, tobacco, or drugs. Diagnosis: femur fracture, tibia fracture, humerus fracture, liver laceration, compartment syndrome of the right hand, compartment syndrome of the right upper extremity. Allergies: none. Support System: both parents (mom and dad) (live in another state). Has 2 siblings (make it up). Occupation: none. Single. Highest grade completed: high school. Weight: 180 lbs. Health insurance: N/A. Significant primary caregiver: the mother. Language: english.
For diagnostic results: make up some diagnostuc exam name and results that prove any of the diagnosis above.
Surgical Procedures: N/A
Past Health history: make it up, put hypertension
History of Present Illness: Write the following: Presented as a transfer from another hospital. Found to have multiple injuries including a displaced right humeral fracture with right axillary artery occlusion. Patient was transferred and underwent orthopedic intervention and right axillary artery interposition bypass with right axillary and brachial embolectomy with fasciotomies. Admitted to ICU post operatively for further managment and neurovascular monitoring. Injuries include: right axillary artery occlusion. right proximal humerus fracture left femur shaft fracture with distal intraarticular extension left tibia shaft fracture intraparenchymal liver laceration. Patient underwent right axillary artery interposition bypass with reveresed left greater saphenous vein right axillary and brachial embolectomy, right carpal tunnel; release right hand fasciotomies volar right forearm interposition.
For review of systems: this is all subjective data meaning its what the patient says, you can use the example as a reference and make sure its as detailed and make sense with the pt’s history.
For the Health Assessment: You can use the attached example document of how to write. Make sure this is detailed please and that it relates to the pt’s history. IT NEEDS TO MAKE SENSE.
Some abnormal things to include for this assessment (include the normal things yourself please) these are key points.
For patho, use the diagnosis and describe it using APA 7th edition with in text citations.
Baseline and Current Vital Signs: BP: 141/87, Pulse: 74, RR:18, SPO2, 98%.
Allergies: none
Diet with rationale: Regular diet because they have no limitations to their diet. explain a little more.
Activity Order: fall risk Limitations: N/A
For labs, use the following (APA CITATIONS TOO FOR RATIONALE) put the unit as well for each
Creatinine 1.48 explain why its important to check it.)
Calcium 8.0 explain why its important to check it)
BUN: 26 explain why its important to check it)
Hgb: 11 and Hct: 35 explain why its important to check it)
For IVs: put N/A
For Medications, Include the following:
Quetiapine 300 mg 3 tab oral at bedtime, amlodipine 10 mg 1 tab oral daily, oxycodone 2.5 mg 0.5 tab oral every 4 PRN as needed for pain, and ondasteron 4 mg 1 tab oral every 6 hrs PRN as needed for nausea.
Make sure to use in text citation in APA format for rationale, therapeutic range, and nursing implications. please include the therapeutic range. make sure to include generic and brand names.
For nursing theorists, must find the theory use at least 2, and explain it using APA in- text citations.
For the 3 Nursing Diagnosis, MUST USE NANDA #1.
Make sure the first diagnosis put on the list is the one that you FULLy elaborate on. When describing the rationale of importance, make sure it is APA citation.
NOW:
When explaining the nursing diagnosis with the goals sections, follow these instructions and the ones on the sample.
– Make sure to write all three nursing diagnosis, but only dive into the most important one and write one short term goal with one long term goals and 3 interventions per goal and a rationale per intervention. YOU MUST TAKE INTO ACCOUNT CULTURAL CONSIDERATIONS.
nursing interventions must have the person completing it, the action, frequency and what’s the role of the nurse. cultural considerations and mention the suicide hotline for the discharge teaching. make sure to use credible sources. make sure to use in text when necessary as well. thank you
– for subjective and objective data, info may be made up.
-Expected outcomes must be realistic and measurable. please make sure that each goal has 3 interventions. Nursing interventions must state action, frequency and person who is going to carry these out. Patient’s cultural, developmental and psychosocial status must be considered in nursing interventions
For the discharge plan, include how you will educate the client and the family among other things.
FOR THE GENOGRAM COMPUTED AT THE END:
MUST CONSIST OF PAST 2 GENERATIONS. MAKEUP THAT. this can be computer generated. do not forget this, put this at the end
Make sure this has a reference page at the end with all the references!!!Please make sure it sounds complete and realistic
Thank you!!Please make sure its well organized and you adhere to my instructions, thank you. Please make sure its well detailed with no grammatical errors.
MAKE SURE YOU USE CREDIBLE SCHOLARY SOURCES
