Client Room 59, she is 79-year-old admitted for high blood pressure, dizziness headache. Primary diagnosed with brain mass.
– Code states: limited resuscitation
– Allergies: codeine
– History of COPD, tobacco use, and type 2 diabetes mellitus
– Vital signs were stable, but blood pressure was 179/97 in the morning and improved to 138/72 in the afternoon by BP meds.
– Neuro/psychosocial: Alert, awake
– Activity/Rest: feels Weakness, uses a walker.
– Cardiovascular: WNL
– Respiratory: Resp is 16 and O2 is 98. Shortness of breath due to asthma
– Nutrition & fluid balance: Regular appetite, no difficulty eating
– Skin: Dry and warm, no wounds, no drains.
– GI: Bowel sounds normal, active, and present. Last bowel movement was on 5/23/23
– GU: No abnormalities
– Emotional support provided by staff and family
Lab values
glucose 300 normal limt 70-99
WBC 13.1. Normal limt 3.0 – 12.9
RBC 5.12 NL 3.60-5.15
Hematocrit 45.4. NL. 34.0 – 45%
Platelet count 371 NL 130-370
-Meds
Carvedilol tablet 50mg
Dexamthosone injection 6mg
ioratdine (claritin) 40 mg
polyethylene glycol (miralax) 17 gram
umectidium 62.2 mcg inhaler
insulin glargine 18 unit
_____________________
Patient Summary

Name: Client Room 59
Age: 79
Sex: Female
Diagnosis: Brain mass
Allergies: Codeine
History: COPD, tobacco use, type 2 diabetes mellitus
Vital signs:
BP: 179/97 in the morning, 138/72 in the afternoon
HR: 80
RR: 16
Temp: 98.6°F
SpO2: 98%
Neuro/psychosocial: Alert, awake
Activity/Rest: Feels weakness, uses a walker
Cardiovascular: WNL
Respiratory: Resp is 16 and O2 is 98. Shortness of breath due to asthma
Nutrition & fluid balance: Regular appetite, no difficulty eating
Skin: Dry and warm, no wounds, no drains.
GI: Bowel sounds normal, active, and present. Last bowel movement was on 5/23/23
GU: No abnormalities
Emotional support provided by staff and family
Lab values:
Glucose: 300 (normal limit: 70-99)
WBC: 13.1 (normal limit: 3.0 – 12.9)
RBC: 5.12 (normal limit: 3.60-5.15)
Hematocrit: 45.4 (normal limit: 34.0 – 45%)
Platelet count: 371 (normal limit: 130-370)
Medications:
Carvedilol tablet 50mg
Dexamethasone injection 6mg
Ioratdine (claritin) 40 mg
Polyethylene glycol (miralax) 17 gram
Umectiduim 62.2 mcg inhaler
Insulin glargine 18 unit
Nursing Diagnosis

Risk for falls: The patient is at risk for falls due to weakness, use of a walker, and shortness of breath.
Impaired physical mobility: The patient is experiencing impaired physical mobility due to weakness and shortness of breath.
Ineffective airway clearance: The patient is experiencing ineffective airway clearance due to shortness of breath.
Risk for infection: The patient is at risk for infection due to high blood sugar and COPD.
Noncompliance with medication regimen: The patient is noncompliant with medication regimen due to cost and forgetfulness.
Nursing Interventions

Risk for falls: Implement fall precautions, such as using a bed alarm and side rails. Assist the patient with ambulation and provide assistive devices as needed.
Impaired physical mobility: Encourage the patient to participate in activities of daily living as tolerated. Provide assistive devices as needed. Assist the patient with ambulation and provide assistive devices as needed.
Ineffective airway clearance: Administer bronchodilators and expectorants as ordered. Encourage the patient to cough and deep breathe. Suction the patient as needed.
Risk for infection: Monitor the patient’s temperature, WBC count, and sputum culture results. Administer antibiotics as ordered.
Noncompliance with medication regimen: Educate the patient about the importance of taking medications as prescribed. Assist the patient in accessing financial resources to help pay for medications. Develop a medication schedule that is easy for the patient to follow.

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