nursing project and need support to help me learn.
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
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
Carvedilol tablet 50mg
Dexamthosone injection 6mg
ioratdine (claritin) 40 mg
polyethylene glycol (miralax) 17 gram
umectidium 62.2 mcg inhaler
insulin glargine 18 unit
Requirements: as need
NURS 411: Concepts of Adult Health Nursing I
Care Plan Assignment
Clinical Assessment Information
**Also Include information that is abnormal or fundamental for care.
MEDICATIONS (list all medications prescribed that relate to primary diagnosis and any YOU gave during care)
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