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I need about nursing care plan. Please read carefully. thanks Nursing Care Plan Assignment Case Study – Bacterial Pneumonia Linda Cerullo is a 56-year-old female who was brought to the hospital by ambulance on January 25, 2021. She presented to the emergency department and was diagnosed with left sided bacterial pneumonia. She has a history of iron deficiency, high cholesterol and hypertension. Past surgical history includes a caesarian section. She is taking ramipril 10mg PO, daily, atorvastatin 20 mg PO, daily and ferrous fumarate, 300 mg, PO BID. She has an IV of 2/3 & 1/3 running at TKVO in her left hand and is currently on IV ceftriaxone 1gm q24 hours plus Tylenol 1g, PO q6H prn for fever or pain. Linda is currently a secretary at a dental office. She lives at home with her husband and her adult daughter. She is Italian by birth and attends Roman Catholic mass weekly. At home the family speaks Italian but she is fluent in English. She is a full code status and has allergies to penicillin and vancomycin. Linda wears reading glasses. Today is the second day of her admission and you are the nurse caring for her on the medical unit. Upon your assessment her vital signs are temp 38.9 degrees Celsius, pulse (radial) 99 beats/min, RR 24/min, BP 118/79 and O2 sat 92% on 2L of oxygen via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL. She has a productive cough still and complains of being short of breath frequently. You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization. There is evidence of accessory muscle use (abdominal breathing). When asked if she has any pain the patient states “Yes I have pain when I breathe deeply or cough.” She rates her pain as 2/10 at rest and 6/10 when breathing deeply or coughing. You ask Linda when she first noticed the pain, “I first noticed the pain at 5am today”. Linda explains to you that she is feeling “unwell and tired”. She expresses frustration with her inability to sleep due to noise in the hallway at night. She also reports difficulty in getting into a comfortable position to rest as she normally sleeps on her side at home but gets very short of breath when lying down now. You notice she is short of breath during the interview. She can get no more than two words out before having to stop talking and rest. You compare that to the blood pressure that the previous nurse had obtained overnight from the patient. Her blood pressure overnight was 99/69. You recognize that this was lower than normal and ask her if she gets dizzy or lightheaded. She tells you that she is not now but sometimes when she gets up suddenly she does get dizzy and lightheaded. Linda also expresses frustration to you about being constipated, “I think I need some bran flakes. I haven’t had a bowel movement in 2 days”. She says that her medication makes her constipated but at home she is active and drinks more fluid to assist with this. Her abdomen does appear distended. You auscultate for bowel sounds and note that they are hypoactive in all 4 quadrants. You palpate all four of her abdominal quadrants and note they are slightly firm. She tells you that a month ago she was 135lbs but when came to the ER she was only 128 lbs. You ask her why she thinks she has lost weight and she says, “I haven’t eaten well since I started to get sick almost 2 weeks ago. I haven’t had an appetite and it takes a lot of effort to eat due to my shortness of breath.” Linda eats a low cholesterol, regular diet at home. Her bloodwork showed a WBC is 16.2 and her CXR shows consolidation to the left lower lung. Nursing Care Plan Part 1 Template – 5% Data Collection Data Clustering Prioritizing 1. Patient information and assessment data collection Review and collect the assessment data about your client in the case study. Name DOB/Age Date of Admission Date of Assessment Gender Identification Allergies Code Status Religion Admitting Diagnosis ­­­ Past Medical History (diagnosis and date of diagnosis if possible) Past Surgical History (diagnosis and date of diagnosis if possible) Medication Dose Route Frequency Reason YOUR patient is taking Vital Signs Temp HR (Pulse) BP RR O2Sat on R/A or amount of O2 Pain O = Onset P = Provocation/Palliation Q = Quantity/ Quality R = Region/Radiation S = Associated S&S T = Timing U = Understanding Last Pain Medication? Effect? Sleep & Rest Sleeping patterns (#h/d) Naps Use of sedation Feeling rested? Mobility Gait, balance Independently ambulatory W/C, Walker, Cane, Crutches Bed ridden Level of assistance required for movement (transferring, getting out of bed, walking) Neurological Level of Consciousness Orientation Mental Status GCS Number Communication Language Vision Hearing Cardiovascular Radial pulse – rate, rhythm, strength Apical pulse – rate, rhythm Heart valve characteristics Capillary Refill Peripheral Pulses X 4 BP Edema – description, extent, pitting or non-pitting Respiratory Respirations – Rate, Rhythm, Depth, Characteristics, Adventitious Sounds Cough (productive or non-productive) Secretions Suction Requirement O2 Saturation Oxygen Therapy Gastrointestinal Abdomen shape, Scars, Lesions Bowel sounds Abdominal palpation BM – last one, usual bowel patterns Bristol bowel movement description Continent/incontinent stool Height Weight BMI Diet Amount consumed Ability to eat, physically and psychologically Genitourinary Continent/incontinent urine Catheter Condition of Perineal Skin Discharge/odor Urine Assessment – characteristics, amount Musculoskeletal Upper body strength Lower body strength ROM Contractures/abnormalities Integumentary Colour Temperature Skin Texture Skin Turgor Lesions/wounds Scars Braden scale Ability to manage hygiene need Psycho-social (SELFACNG) S – Self-Esteem: pertaining to hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient’s self-esteem, Sense of self, in relation to the world, Sense of meaning and purpose, Value base, Evidence of Emotional Distress, Grief Issues E – Energy Level: Patient’s with psychological problems often have an alteration in level of activity. L – Lifestyle: Living arrangements, significant relationships, occupation, hobbies or lack of interest in leisure activities, education, and any other data that provides information about the patient’s personal situation. F – Family System: contact and support from family members or significant others, family stressors, crisis events, and coping skills. A – Affect: mood or emotional feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms. C – Culture: refers to all cultural, racial, or anthropological variables that influence one’s lifestyle and mental health, may refer to issues of homelessness, religious and spiritual preferences, if any. Discuss any related food needs and other areas of impact culture will have on their health status. N – Needs: As expressed by the patient G – Goals: As expressed by the patient Lab Values & Diagnostic Tests Date of lab work Normal value Tubes Insitu IV / central line / PICC, Foley catheter, NG, PEG/G-tube, drains IV site, solution, rate Safety Falls Risk Safety Measures – call bells, bed rails, seatbelts, lap tray Psychological Security Discharge Plans/Care Discharge teaching Care on discharge 2. Clustering of Data: Cluster assessment data from above into the boxes below. From the list of assessment data, you collected, group similar data together. These groupings will help you to identify the health problems for your client. Put a ‘name’ to the problem in the blue box at the top of each cluster, e.g respiratory, priority 1 priority 2 priority 3 priority 4 3. Identifying 1 priority problem area (rank 1-4): go back to the cluster sets above and rank them from most urgent (#1) to least urgent (#4). (This will be dependent on the amount of abnormal data in each box and the severity of the abnormal data, e.g., breathing will be more of a priority than constipation).

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