Reference no: EM133635927
Case: Mr. Clooney is a 76-year-old Caucasian male admitted to the rehabilitation hospital following a 6-week stay in a local acute care hospital. He suffered a T3 burst fracture after an MVA, and the site was surgically stabilized. He is paralyzed in his lower extremities and has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure ulcer to his coccyx. Medical history includes asthma, substance abuse (alcohol), obesity, constipation, prediabetes (has not progressed to type II diabetes), and tested positive for COVID-19 in November 2020 after experiencing shortness of breath and fever.
Mr. Clooney is single and lives alone in a second-story apartment. His son lives three states away and has no relatives in the area. He is a retired construction worker, denies any religious affiliation, and speaks English.
Orders include:
Full resuscitation
PT, OT TID, 5 days per week
Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily
Cervical collar when OOB
Transfer with sliding board per PT
Regular diet
Ensure high protein shake BID
Foley catheter to dependent drainage
Cleanse catheter site with soap and water BID
Medications Include:
Dulcolax suppository every 3 days rectally
Baclofen 5mg PO QID
Midodrine 10 mg PO at 0800, 1300 and 1800
Albuterol inhaler: 180 mcg (2 puffs) every 6 hours PRN
Metformin 500 mg PO BID
Medical history- Describe the pathophysiology of the medical diagnoses of your assigned patient. Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis is the reason for being in the facility. If post-surgical, include surgery and reason for surgery. If your client is in a long-term care facility, why do they need 24-hour nursing care? The secondary diagnoses include a history of pre-existing medical diagnoses. You need to have four secondary diagnoses. For each diagnosis, provide at least a five sentences explanation of the pathophysiology of the condition/problem. This section should be at least two pages in length. MAKE SURE YOU CITE YOUR SOURCES.
Nursing Care Plan- Upload the table below into your paper. Include four nursing diagnoses, one short-term and one long-term goal PER NURSING DIAGNOSIS, and four interventions PER NURSING DIAGNOSIS (not per goal, unless you want to). One nursing intervention should be an assessment; two nursing interventions should be nursing actions; one should include client teaching. Then, in one paragraph, prioritize your nursing diagnoses per Maslow with an explanation and an expected evaluation. Make sure to have a teaching plan in your care plan. Reflect on the following in your paper: Which of your nursing diagnoses are priorities using Maslow's Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term desired outcomes to be met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift?