CARE PLAN - NURSING - Management Tutors

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PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week:

Dates of Care:

Patient Initials

M.R

Sex
F

Age
62

Room
616

Admitting Date
5/27/2022

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Right knee Arthrotomy
Right knee patella revision

Attending physician/Treatment team:

Frisch, Nilesardo, Maya, long K Ham

Consults:

Hospitalist group, Md

Present Diagnosis: (Why patient is currently in the hospital)

· Left wrist pain

· Right knee pain

· Moderate episode of recurrent major depressive disorder (HCC)

· Panic disorder with agoraphobia, mild agoraphobic avoidance, and mild panic attacks

· Numbness and tingling in both hands

· Mass of left wrist

ER Management: (if applicable)

Total knee replacement
Right knee patella revision

Allergies:

Niacin and Related

Code Status:
Full code

Isolation: (type and reason)
None

Admission Height:

170.2 cm (5’7)

Admission Weight:
124.7 lg (275 lb)

Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)

No problem with communications. Can speak English and there were no language barriers.

Past Medical History: (pertinent & how managed)

· Anxiety
· Arthritis (pt states osteoarthritis)
· Asthma

· Depression

· Diabetes mellitus (HCC)

· Diabetes mellitus, type 2 (HCC)

· General weakness 2 to S/P. Lt. TKR (total knee replacement) using cement

· GERD (gastroesophageal reflux disease)

· Hypertension

· Migrains

· PONV (postoperative nausea and vomiting)

· Right knee pain

· Stroke (HCC) TIA x2 in 2011 and 2012 with LUE weakness

Significant Events during this hospitalization but not during this clinical time: (include the date, event and outcome)

A 62-year-old Hispanic female with a history as noted below presents for the elective procedure(s):
The patient states did well after bilateral TKAs in 2014 but fell on R knee 2-3 months ago and has had patellar pain since that time, especially with weight-bearing, flexion, and turning Saw their care provider with concern for loosening of the prosthesis. No recent or other UTI/URI sx, chest pain, shortness of breath, orthopnea, PND, dizziness, syncope, palpitations, LE pain/swelling, fevers/chills, headaches, confusion, numbness/tingling/weakness, speech/swallowing/vision changes, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena/hematochezia, or COVID symptoms.

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

0942

1322

98.3

98.2

B/P

143/63

149/77

Time

1355

1425

98.2

98.5

B/P

154/72

170/69

GI:

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation:

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA:

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

10.0

RBC

4.20

HGB

12.4

HCT

36.4

MCV

86.7

MCH

29.5

MCHC

34.0

Platelets

12.9

RDW

198

MPV

7.3

N/A

INR

N/A

APTT

N/A

Glucose

188

BUN

Creatinine

0.75

Sodium

138

Potassium

3.9

Cloride

103

Calcium

9.0

T Protein

N/A

Albumin

N/A

SGOT

N/A

SGPT

N/A

Alk Phos

N/A

Magnesium

N/A

Amylase

N/A

Lipase

N/A

CPK

N/A

LDH

N/A

Cholestrol

N/A

CK-MB

N/A

Troponin I

N/A

Myoglobin

N/A

LDI

N/A

Urinalysis

N/A

Color

N/A

Character

N/A

Spec. Grav.

N/A

Protein

N/A

Glucose

165 (H)

Acetone

N/A

Bilirubin

N/A

Blood

N/A

Nitr

N/A

Urobili

N/A

RBC

N/A

WBC

N/A

Epithelium

N/A

Urine Culture

N/A

Chest X-ray

N/A

MRI

N/A

CT Scan

N/A

Others test:

N/A

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary caregiver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Morphine PF

Injection

4mg

Intravenous

Every 4hrs PRN

Severe pain breakthrough pain

Aluminum & Magnesium hydroxide (Maalox plus)

15ml

Oral

Every 6hrs PRN

Indigestion

Docusate sodium (Colace) capsule

100 mg

Oral

2 times daily

Constipation

Enoxaparin

(Loveriox)

40mg

Injection Subcutaner

Every 12 hr

Gabapentin

(Neurontin)

300 mg

Oral

Every 8 hrs

Ibuprofen
(Motrin)

600mg

Oral

Nightly PRN

Ketorolac

(TORADOL)

Injection

15mg

Intravenous

Every 6hrs

Oxycodone

(Roxicodone)

10mg

Oral

Every 4hrs PRN

Immediate release, Severe pain

Hydroxyzine
(ATARAX)

25mg

Oral

Nightly PRN

Itching, sleep

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

PAGE
1

RIGHT KNEE ARTHROTOMY .

Pt states did well after bilateral TKAs in 2014 but feel on R knee 2-3 months ago and h as h ad
P’;’fellar pain since that ~ime , especially with …:,eight-bearing , flexion , turning . Saw Dr . F risch
with concern for loosening of prosthesis . No recent or other UTI/URI sx ch est pain , sh ortness
of breath, orthopne_a , PND, dizziness , syncope , palpitations , LE pain/s…:,elling , fevers/chills ,
he’.3daches, confus~on , numbness/tingling/weakness , speech/swallowing/vision changes , back
pain, abdominal pain, nausea, vomiting, diarrhea, constipation , melena/hematochezia , or
COVID symptoms . ”

Onset (date of injury,illness, surgery): 5/27/22

General Observations: Patient lying supine in bed with CoolJet ice pack on R knee and
RN present in room providing pain meds.

Precautions: Fall risk

Pain Scale:1,/10
Location: R knee

Prior Level of Function (PLOF): Patient was independent with ADLs/lADLs at baseline.

Previous Living Environment: Lives in an apartment building with elevator

Equipment Owned/At Home: Rollator, SPC

SUBJECTIVE: “I’ve been through this before”

OBJECTIVE:

COGNITION:
Orientation: A&Ox3
Follows Commands: able to follow 2-3 step commands
Attention: intact

~:,~~rx~;~:~tess: demonstrates good FWW awareness, pacing self during tasks

VISUAL/PERCEPTION:
Acuity: read time on clock: intact
Other: NIA

HAND DOMINANCE: right

SENSATION: . · ht T h· intact
Right (R) upper extre~1ty (UE)_ Lrg ouh~ i~tact
Left (L) upper extremity (UE) Light Touc .

COORDINATION:
Gross motor: .
Right hand finger to nose_: intact
Left hand finger to nose: intact

Fine Motor: . · t ct
Right hand opposition tip to tip: ,n a L

~ :::::::—–_ -=’—·–
an of cafe.

_P 3-5 days/wk I n of care .
· goals/pa heraPY _

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TREATMENT PROVIDED THIS S . . . and completed . · ESSION : Order received chart reviewed evaluation initiated

Bed mobility , t ransfers , gait training and CPM set up

HO~E EXE~ CISE PROGRAM(Specify exercise): LE strengthening
Pat1ent/Fam1ly verbalized/demonstrated good understanding.

EDUCATION/DISCHARGE INSTRUCTION:
Therapist provided education on the following topics : energy conservation , goals , positioning,
role of PT, treatment plan and role of PT.

Follow ORTHO Protocol (Ortho patient ONLY. YES/NO): yes

ASSESSMENT: Patient seen after R knee Arthrotomy who presents with decreased
ambulation tolerance, pain in R knee, decreased R knee ROM and strength of LE,
decreased dynamic and static balance without device. Patient at increased risk for falls
related to impairments. Pt to benefit from skilled services to improve balance, strength,
ROM, gait to return to PLOF

Stroke Modified Rankin Scale: GCS NA

Recommendations : Initiate/continue PT services

Equipment Needed Upon Discharge: Rolling walker

Interventions: Transfer Training , Gait Training, Balance Activities , Therapeutic Exercises and
Neuromuscular Re-Education

Discharge Destination : Home

TREATMENT FREQUENCY: 5xs a week

PREDICTED DURATION OF THERAPY: 1 week

SAFETY EDUCATION: Therapist assisted patient with set up of CPM at 70 degs as per Rn
request. Therapist waited for patient to go through two full cycles before leaving. Patient
expressed no discomfort however requested place of icepack on R knee for pain
management. Therapist left patient with DVT cuff on LLE, CPM on R LE at 70 deg with ice
pack on there. All needs met with call light in reach; educated to call RN if requiring
assistance. Patient with good understanding of how to stop machine

.. .. •o .. “”‘ dw;:,a15 ,a;:,.l. 11c cu ro oe compared before th .. ,< ct · •. pass. e next me 1cat10n - II . ' O_BJECTIVE: . _ . J..Jl 7 H1Story of Present Illness: Patient 1s a 62 yo female wOh hx of bilateral TKAs 1n 2014, fell on R _ knee 2-3 months ago and has had patellar pain since then during WB , flexion and turning . "' Patient with procedure 5/27 for R kne Arthrotomy. · Date of Onset: 5/27-surgical date PT Diagnosis: Decreased functional mobility. Precautions/Weight-Bearing Status: WBAT General Observations: Patient supine in bed with bilateral DVT cuffs and ice pack on R knee VITALS: supine: BP: 149/77 mmHg HR: 62 bpm SpO2: 98% COGNITION Status Orientation oriented x 3 Ability to Follow follows Commands commands Attention Intact Memory Intact Safety Intact Awareness LOWER EXTREMITY RIGHT LEFT LOWER LOWER EXTREMITY EXTREMITY Limited knee WFL Range of flexion to 70 deg Motion passively Limited 4/5 Manual Muscle assessment due Testing to pain OTHER STRENGTH/ ROM: Patient limited assessment of RLE due to pain and swelling COORDINATION No Deficits - - -- - -- --c::, .. - -- ~- ~=o '""I. ucc:u co oe compai-c:u oerore the ne~ 1:u11.;anon nass . u Left hand opposition tip to tip : intact MUSCLE TONE: ,,,.-- Right Upper Extremity (UE) : WNL 7 Left Upper Extremity (UE) : Decreased muscle tone d/t previous CVA ACTIVE RANGE OF MOTION: /"- Right Upper Extremity: WNL 4117'3 Left Upper Extremity: WNL -- GROSS MUSCLE STRENGTH: / Right Upper Extremity : Grossly 4+/5 Left Upper Extremity : Grossly 3+/5, residual CVA symptoms BALANCE: Static Sitting : good Dynamic Sitting : good Static Standing : fair plus Dynamic Standing : fair /Ji~ un 0>/

BED MOBILITY:
/ Supine to Sit: supervisoin

Sit to Stand : close supervision

Bed to Chair: did not assess this date

SELF-CARE:
Eating/Feeding : independent
Grooming : set up assist for standing at sink tasks including wash ing face
Upper Body (UB) Dressing : NT, deferred this date
Lower Body (LB) Dressing : set up assist with AE including sock aid for doning/doffing socks
Bathing : NT
Toileting : NT
Toilet Transfer: NT
Shower/Tub Transfer: N/A at this time
Homemaking : NIA at this time

ASSESSMENT:

Patient’s response to occupational therapy interventions : good . Patient with prev ious B TKA
and residual CVA L sided weakness . She requires increased time to complete tasks , however,
was able to demonstrate bed mobility and functional transfers with close supervision . Patient
familiar with AE including sock aid and reacher, re-educated on use of AE . Patient able to
tolerate long functional mobility in hallway; educated on pacing strategies and energy
conservation techniques to improve activity tolerance . Discussed DME as patient currently does
not have shower chair at home . She would greatly benefit from a tub transfer be nch to improve
safety with showering d/t balance deficits . O.T. encouraged AOL engageme nt and safe
performance .

THERAPY PROBLEM LIST : Patient presents with decreased activity tolerance, res idual L
sided weakness from prev ious CVA, balance defi cits wh ich li mit the pati ent’s safety and
independence wit hin AOL and functional mobility/transfers .

THERAPY STRENGTHS : coope rative , pleasant, motivated
,..A t

GOALS:

PATIENT/FAMILY THERAPY GOALS: To go home

SHORT-TERM GOALS (STG) (1-3 treatment visits)
Patient will perform:
1. Increase standing tolerance to 1 O+ minutes with reports of minimal pain to improve activity
tolerance
2. Demo sock aid with no verbal cues to increase independence with LB dressing
3. Retrieve 3 AOL items in room using Fl.NIN with close supervision

Occupational Therapy Plan of Care

Reason for Referral : impaired AOL skills, UE weakness, impaired balance , and pain

Recommendations : Will continue to see patient for skilled OT services while in house

Interventions: therapeutic exercise , self care/AOL training, balance activities , energy
conservation, home exercise program, and family/caregiver training

Planned Frequency & Duration of Treatment: 3-5 days/wk

Additional Services: physical therapy evaluation

Discharge Destination: home with assist and home with OT

1111 Rubric Assessment – NUR4641–03:Adult Health N111Sing II (2022 Somrner’fenn l )- :.-;378 – &.”Surret;tiarj l’Jn~tr – Gopgle €hrome X

i https://oakpoi nt.brightspace.com/ d21/lms/compete ncies/ru bric/rubrics_assessment_result s.d2I?ou= 17846&evalObjectld= 37032&evalObjectType = 1 &userld = 360 …

‘1’1 11
18 Print Rubric

Good Fair Poor Incomplete
4 points 3 paints 2 points 11,i O points

– – – ——-t——-~ –i———–+— __ __ ___,,L:wL .. __ ___ _ _
Criteria

Criterion
Score

Patient
information and
health
assessment:
Complete patient
demographics,
health
assessment and
inte rvent ions

Pert in ent
Dia g)1os tic _Dat1: __

All of the
demographic
section is
completed, all
areas of the
health assessment
is completed
interventions1 are
identified for ~h1e ,,,
health assessment
data that is
identified.

Identified al l of
the abnormal

Ii’

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11

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half to 2/3rds of ‘ 1111 demograph jc
th d h• i f . 11111 . e emograp 1c n

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.
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ormatio n 1s

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,

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complete. Tl;ie 1 111 11 ,care plan, ma l’.Jy • I 1I1I ” I, 111,’1 l1l’i’I

‘111i’il 111
I

health lj:ISSessr:hent a~ea!i l1<',~Ithe 1111 1 1,1 ,I ''111'1 I i'1111 11lh, 'l1'1lI1', 1I I Iis 1at least 1~a lf 11,1 I l11 t1~1alth a1s~ess~ent , , I 11'1 " i11li111 '· I I I 111111111' ,' l111 l1l1' 1 1 complete and l!i ' 1 1, 111 seatio n a~f:! 1 1 11 j ' I 'I ifl1 1111 l11I 'l11'l aacuratel',1 1 1/,/ I I1ii1i111o mitted, I 1i 11 1 ,· I 1,1,1," I 1111'111, l1 1<1 1 idenMied 111 11 1 1 11 11111 i'nte rve ntiops areI I I Ill 11, I I 1111 I aftlloughi'i!i11ini~Ial 11 I lim ited . I' ' . I .1,, 11 '111 I I I 'I · 1 1· 1nterve 'ltion~I,ar~ 1111' 11 111 1 11 'lI I 11',11', 11,1 II 1I1I' I , 1 ,, 1, still ,1ot~f!, bas11~1 ,1, 11 11 , 1'11111' '1i1/1 , , No Demographic info~mation is 1, noted in the care l'l 11' pla'n; health 1I 1I assessment and 1'1l11 interventions are I not identified 1 I ' i1 correctly. ,1 I' on th ~' h~~lth l1,l11' I 1111'1I 1111,1 1\,11, '1, 1I Ii ," ' 1,111[1 ,i1,11, I 1 1 11 1 111'11' 1I 11 I I ass~ssm e11 t dat1 eo II11 11 11' l1 1 1 1 1,1, 11'111' '1, 1, '11 I'll ' I 1 'I I I 11' ,',[ 111 I gather7,~ ,1' 'l,11', 1,I 1l1', 'l\1l1 I 1, I' I ill I I '1 I %1'1I 11'11' ,li11 ,l,l I l1111 1111 II ' I ' I I I 1" 1 '1 111 1 1111 I 11 I ,,1 .. 1, , 11 11, . 'I' 111-1 1 r,· I· I' ,.,, · , • • ·1' /4 I I ,11,,,, ',1,1l1 1'11 11 I 11, 1111 I I,' I I I i1 11 11,1 I 111 1 111, I 111 1]1 I '1l I I' 'I / ' lde ntilie'q1a11I Qf ''1'1'1 ' 1111 I 'i1 ld1=nt1fli ed h~lf of NI O Diagnostics 4 I ,,,, ,,,, 1,11 " '1 I I ii, 11 11 Ill 11 .. ,, 1the ab,~brma,I 11 1 111 ,11, the alJnorrna l , were 1d ent1f1ed --,= ,,., ,.,, '"l""rl"'l1'""TID'1"' 111ll~l '11Tim~11~1111111q "'iii! 11111Til111il 1'111ll' lll'l 111 '" I ·wrnnn=~~=~ .. -- ~- 1 II Rubric Assessment - NUR4641 -03:Adult He,, fth Nursing II (2Q2 S~mmer Term 1)-14878 - Resurrection University - Google Chrome i https://oa kpoint.brights pace.com/d21/lms/competencies/rubric/rubrics_a ssess me nt_re sults.d 21?o u = 17846&eva l0bjectld= 37032&eval0bj ectType= 1&userld= 360. Pertinent Identified all of Identified all of Identified half of No Diagnostics /4 Dia gnostic Data: the abnormal the abnormal the abnormal were identified Identify abnormal diagnostics and diagnostics and diagnostics and for this patient. diagnostics, state stated the wa~able to state was able to state significance for significance fo r SOME of the SOME of the this patient. this patient. significance for significance for this patient. this patient. Number of Identified 5 Identified 4 Identified 3 I Identified 2 /4 Nu rsing nursing diagnoses nursing diagnoses nursing diagnoses I nursing diagnoses Diagnoses: for the patient for the patient for the patient I for the patient Provided 5 that are correct that are correct that are correct that are correct correct nursing based on the based on the based on the I based on the diagnoses for the patient patient patient I patient patient based on 11 a~~essment, assessment, assessment, I assessment, the patient histo ry and data history and data history and data history and data. health 1i ,, I assessment , ,',,I history, labs, and , pathophysio logy. I . I ..... j'" ······- -· ---- Pathophysiology: Explanation of No explan ation of No explanation of Not identified / 4 Disease process pa t hophysiology pathophysiology patho phys iology co rrectly or I h . chosen ;__g~ D,,.Yid.tl;L,-._,fj1os.~1,K_g ive n r ..£Q!L~ctLv . ~-.Ji.e.scr.i.oiino ____________ ---~ .. 9.S .. f;D_;_gJve n Pathophysiology: Disease process descri ption including "Signs and Symptoms" as well as APA references cited Pharmacology: Complete and accurat e description of current med ication list t hat includes 1 descripti on of medications, side effe cts as w ell as nursing con siderations I I Explanation of pathophysiology chosen; given with accurate details related t o cl ient's symptoms and current illness. APA references noted List all MAR meds with description, side effects and nursing cons iderations . . spec1f1 c to pat ient and w hy patient is receivi ng drug I No explanation of No explanation of pathophysiology pathophysiology chosen; given with chosen ; given acctl rate details with accurate related to client's details related to symptoms and client's symptoms current illness. and current APA references illness. No APA noted references not ed Most of t he MAR I List some MAR meds wit h I meds but does description, side not inclu de effects and I relevant side nursing effec t s and considerat ior. 5 nursing specific to patient con siderations and why patient is I spec ific to patient rece ivi ng drug I I Not identified correctly or correctly identified although w ith many omissions not ed. The pat hophysiology is not integrated into the plan of ca re --- Only some of the current meds are written & discussed in the meds section. Info is incomplete w ith many omissions noted. The meds are not integrated in t he plan of care /4 J_ - I I /4 I I I I I I I I • 66•F p 'all _... w- l['t 1-:"1 n f) x'l'!! S MW P... TJ" 1 Su nn - -:;:, ' Iii ' lill _,, l : I I an Ill[ Kubr._ Assessm e nt NU l{4b4HH :Adull H 1 1 1,

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