CASE STUDY FOR NURSING CARE PLAN

CASE STUDY FOR NURSING CARE PLAN –
STUDENT:- RODRIGUEZ, VANESSA – GROUP 6
Diagnosis: Dementia; Fall; Head injury with rule out subdural hematoma
Lithia Monson, 93-years-old, with a head injury, and r/o subdural hematoma. Hx of dementia, from nursing home, fell one day ago and hit her head. No known allergies (NKA). Vital signs -Temp 97.2_F (36.2_C), BP 96/74 mmHg, pulse 82 beats per minute, RR 20 breaths, SaO2 97% on room air. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today, which is new for her; Neuro assessment and vital signs ordered ever 1 hr. around the clock. Skin warm dry, bruises on the forehead with a small laceration. Increased fall risk. Dry sterile dressing to the forehead laceration is clean and dry intact. 20g peripheral capped IV in the left antecubital. GI assessment within normal limits. Cardiovascular: has a pacemaker with a rate of 82 beats per minute on demand. Her chest was symmetric and non-tender to palpation, and there were no deformities of the chest wall. Her lungs were clear to auscultation. Her abdomen was soft, non-tender, and non-distended, and she was able to move all extremities. On neurologic examination, the patient opened and closed her eyes. Sensation was unable to be assessed due to confusion. Her Glasgow Coma Scale (GCS) score at this time was 14.The patient was taken for CT of the cervical spine and brain. Strict I&O, regular diet, consuming 50% of meals. Family sitter at bedside, assist with bath. Dr. Altace
MEDICATIONS
atorvastatin 10 mg tablet
SIG: give 1 tablet (10 mg) by oral route once daily at bedtime
Colace 100 mg capsule
SIG: give 2 capsules (200 mg) by oral route once daily at bedtime
donepezil 10 mg tablet
SIG: give 1 tablet (10 mg) by oral route once daily at bedtime
Ecotrin Low Strength 81 mg tablet,enteric coated
SIG: give 1 tablet (81 mg) by oral route once daily
acetaminophen 325 mg tablet
SIG: give 2 tablets (650 mg) by oral route daily
Percocet 5/325mg
SIG: give 1 tablet (5/325 mg) by oral route every 8 hours as needed for severe pain
Protonix 40 mg tablet,delayed release
SIG: give 1 tablet (40 mg) by oral route once daily
Keflex 500mg capsule
SIG: give I capsule (500mg) by oral route every 6 hours for 7 days
TREATMENT/MONITORING
Neurological check monitoring
Vital signs monitoring
Monitor for changes in LOC
Fall precautions
Daily dry dressing & PRN and apply Bacitracin Ointment and Observe for signs of infection
Recommended Nursing Diagnosis

Risk for falls R/T as evidenced by ———-
Risk for infection
Deficient Knowledge
Impaired Skin Integrity
Activity Intolerance
Risk for Decreased Cardiac Output