Reference no: EM133396641
Clinical Care Plan: 86-yr-old F who came in for ground level fall. Diagnosed with L1 compression and spine fracture. LOC: alert. Oriented to time, place, situation, person. Face is symmetrical. PERRLA. Wears glasses. Speech is clear. Mood is pleasant and cooperative. Moves fingers, lower legs, lower arms. Cognition is logical and appropriate for situation. Cap. refill is <3 seconds. No edema. PR 78-radial. S1 and S2 heart sounds heard. S3 and S4 heart sounds distant. Apical rhythm regular. Peripheral pulses regular and strong in all 4 extremities bilaterally. No pulse deficits. Skin color appropriate for race. BP 114/74. Oral T 97.8 degrees Fahrenheit. Left calf tenderness. No apnea periods. 94% RA. 16 breaths/min. Lung sounds clear to auscultation. Chest movement symmetrical. Respirations regular, even, unlabored. No cough or sputum. Abdomen hard, round, distended with bowel sounds present in all 4 quadrants upon auscultation. Nausea, constipation, distention present. No tubes. No IV lines. Regular diet with 50% of diet consumed. Skin warm, dry, and intact. Mucous membranes dry. Skin turgor tenting. Pressure injury at coccyx, pre-stage 1. Dressing dry and intact. Surgical wound, middle back. Dressing dry and intact. Left arm and left leg wound dressing dry and intact. Urine yellow, clear. Continent. No foley. No dysuria, hematuria, retention, burning, foul odor. Total assistance with bathing. No weakness or limitations to extremities. Moderate assistance with dressing and toileting. Johns Hopkins score 11. Braden Scale score 20. Surgical history: right hip replacement, bilateral knee surgery, appendectomy, colectomy, hysterectomy, cholecystectomy, esophagogastroduodenoscopy, kyphoblasty T11, kyphoblasty L1. Medical history: Crohn's disease, osteoarthritis, meningioma.
*Rate client problem from highest priority to lowest priority. Change first 2 client problems if needed.*
*Provide a brief background statement.*
Client problem #1: Constipation r/t low-fiber diet and inadequate fluid intake as evidenced by eating only 50% of meals and drinking 2 hospital cups of water per day. (Fix if needed!)
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Client problem #2: Deficient fluid volume r/t inadequate fluid volume as evidenced by drinking a max of 2 hospital cups of water a day. (Fix if needed!)
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Client problem #3: ???
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