Comprehensive Plan of Care (Use the case study attached)

Comprehensive Plan of Care (Use the case study attached)
Develop a comprehensive plan of care/treatment with short and long term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion. Your paper should be between 2 – 3 pages and submit via the drop box.

Case Study

Chief complaint

An 84-year-old man was found by his daughter on the floor of his apartment after failing to answer the telephone for a day. He complained of pain in his left knee, but otherwise is confused and unable to explain what had occurred. He was brought to the hospital by ambulance and admitted.

Past Medical/Surgical History – provided by the daughter

Chronic Obstructive Pulmonary Disease (COPD)

Myocardial infarction (MI) 10 years ago

Hypertension (HTN)

Peptic ulcer disease with bleeding 20 years ago

Benign prostatic hypertrophy (BPH)

Venous insufficiency

Bilateral cataract surgery 5 years ago

Left inguinal hernia repair 25 years ago

Medications:

Aspirin 325 mg daily Atenolol 50 mg daily Multivitamin daily

Vitamin E 800 U daily terazosin 5 mg daily Lisinopril 10 mg daily

Vitamin C 1000 mg daily Ginkgo biloba daily

Social History – provided by the daughter

He lives alone and is able to care for himself. A woman cleans his apartment twice weekly and also does some shopping. His daughter is very involved and calls about every third day. He was a bookkeeper, retired at age 65 and became a widower at age 70. He manages his own finances and enjoys baseball on TV. He denies any recent change in appetite, has some rolls and coffee for breakfast, lunch at the senior center, and for dinner, he usually warms something left by his cleaning lady or eats at a restaurant near his home. He smoked 2 packs a day from age 20 to age 55 when he stopped after an episode of pneumonia. He rarely drinks more than one drink an evening. He does not exercise, and takes his medications as prescribed.

Physical Examination:

In the emergency room, his physical examination revealed a thin, frail male who appears alert but agitated and in moderate pain, lying on the stretcher.

Lung sounds with coarse crackles posterior in the right lung base

His vital signs were:

Pulse 48 Oxygen Saturation 88% on room air Weight 125 lbs

Blood pressure lying down 190/70 Height 5 ft. 9 in.

Respiratory rate 26 labored Temperature 102 F

He has 2+ pitting pedal edema to his left foot, none to the right foot. Unable to palpate a pedal pulse to the left foot. 2+ strong pulse to the right foot. He has obvious shortening and external rotation of the left leg.

 

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