Patient Information and Care Plan Essay

Patient Information

Biographical Data

Gender: Female Age: 70 years previous
Evelyn is a 70-year-old feminine
Patient residing at residence or in residence:
The case research signifies that the household must conduct a gathering for planning on how the affected person might be returned residence. This exhibits that the affected person have to be having a spot of residence, both a private home the place she lives with the remainder of her relations or retirement residence. A retirement house is a house for previous individuals or an previous age residence. However, an previous individuals’s residence can be known as a nursing residence as a result of Evelyn has already attained 70 years of age. Therefore, a nursing house is a multi-residence housing facility that has been constructed for aged individuals to reside in.
In-Patient Unit /hospital (sort of unit):
Admission Date:

Date of Assessment:
It is troublesome answering these questions as a result of the out there knowledge solely signifies Evelyn’s date of beginning, her weight, and peak throughout the time of admission to the hospital.


It is clear from the case research that Evelyn takes Tylenol. This is an acetaminophen medication for complications additionally typically accompanied by sinuses allergy. An allergy headache prompts sinus or nasal congestion which is the explanation why the affected person takes ibuprofen and Tylenol. Some forms of ache relievers comparable to Tylenol which is a light over-the-counter ibuprofen or ache reliever might supply short-term aid for sinus headache ache.

Social History

The social historical past includes all features of the household of the affected person, and medical historical past, and different data that’s related to the occupation, faith, race, and life occasions of the affected person.


  • Family: Evelyn is married with two grown sons.
  • Medical History: The affected person has beforehand recognized with breast most cancers (stage IV), persistent insomnia, osteoarthritis (knees, hips, and palms), and persistent low again ache.
  • Occupation: Retired instructor
  • Note: It is necessary to notice that life the faith, race, and life occasions of Evelyn weren’t indicated within the knowledge that was supplied.


Evelyn receives a lot of the assist from her husband, her two grown sons, medical doctors, and nurses


Presenting downside/Chief Concerns:
Medical History of the Patient: The affected person has been identified with breast most cancers (stage IV), persistent low again ache, and osteoarthritis affecting her palms, hips, and knees. The affected person additionally has persistent insomnia and she or he had a complete arthroplasty on the appropriate hip.
The current downside/chief issues:The affected person has a damaged hip
History of presenting downside (indicators, signs, onset, and so forth.):

  • First, it is very important establish the affected person’s presenting downside
  • Presenting downside of the affected person:the affected person has a damaged hip
  • Signs and signs:the affected person has persistent low again ache, drained darkish circles below her eyes, and infrequently expertise difficulties when sleeping.
  • Onset:throughout the previous three days
Past medical and surgical historical past:
Past Clinical historical past: The affected person has been identified with breast most cancers (stage IV), persistent low again ache, osteoarthritis (knees, hips, and palms), and persistent insomnia.
Surgical historical past: proper complete hip arthroplasty.
Current Medications and Treatments:
The present remedy for the affected person is listed within the knowledge supplied under:

  • Morphine 2-5 mg IV q4hr Tylenol Extra Strength 1-2 tabs Q4hr PRN for Pain.
  • Multi Vitamin PO QDaily Ibuprophen 200-400mg Q6hr PRN for Pain.
  • Vitamin D 1,000 is every day Boniva 1-tab each month on the eighth day of the month.

Assessment knowledge

A cluster knowledge is a set of objects that are just like each other throughout the similar group and on the similar time completely different objects in one other group or cluster.

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On the opposite hand, PT/OT are forms of rehabilitative care merely refers to Physical Therapy/Occupational Therapy. PT goals at enhancing or restoring vary of movement, energy and motion whereas OT focuses on enhancing the motor expertise one requires to carry out every day duties (Wynarczuk et al., 2019).

Needs assist x2 to switch to a chair after 24 hours of mattress relaxation post-surgery post-surgery

In the information supplied, the PT/OT have to be ordered in different hospital or nursing houses that medical staff are already oriented and don’t require orientation in every part else they should do.

System Data Collection

System Findings
Respiratory Patient Respiratory
SpO2 refers back to the stage of oxygen saturation within the physique. It is the measure of the quantity of oxygen-carrying hemoglobin within the blood relative to the quantity of the hemoglobin not carrying oxygen (Kera et al., 2019). The physique requires a sure stage of oxygen within the blood in order that it might probably carry out its operations successfully.
From the case research, Evelyn’s Respiratory signifies: SPO2 99%
Cardiovascular Meaning of Cardiovascular
Cardiovascular pertains to coronary heart and blood vessels
Evelyn’s Heart Rate: 122
Nervous system There isn’t any knowledge given assessing Evelyn’s nervous system
Integumentary Evelyn may probably have an an infection on the web site the place the incision has been performed and within the deeper tissue near the tissue close to her new hip.
Gastrointestinal There isn’t any knowledge supplied assessing the gastrointestinal situation of the affected person
Musculoskeletal The affected person has poor musculoskeletal since she requires assist to maneuver out of her mattress and in addition as a result of she has a damaged hip.
Genitourinary There isn’t any knowledge supplied explaining the genitourinary system of the affected person
Neurovascular There isn’t any knowledge supplied explaining the neurovascular system of the affected person
Pain Data supplied proven the ache scale of the affected person being 8 out of 10
Reproductive There isn’t any knowledge supplied explaining the reproductive system of the affected person
Psychosocial Psychosocial refers back to the affect of social elements on an individual’s conduct and thoughts, and the interrelation of social and behavioral elements. It is probably going that Evelyn has insomnia as a result of she finds it troublesome to go to sleep or keep asleep, she seems drained, and there’s a darkish circle below her eyes indicating poor sleeping habits (Pedersen et al., 2017). Additionally, insomnia is an issue that’s related to psychosocial elements.
Lab Values The recorded lab values areas outlined under:
Lab Values:
Current Weight is 50kg
SP 165/56, HR 122.SPO2 99%

Care Plan

Nursing Diagnosis: PES Statement

The disturbing sample of sleeping related to Chronic Insomnia is evidenced by the looks of the affected person whereby she appears drained with darkish circles below her eyes and by her communication that she has been experiencing issue getting sleep.

Assessment Data/
Defining Characteristics
(Signs and signs supporting the chosen nursing prognosis)
Client Outcomes
(SMART: particular, measurable, achievable, real looking and time-specific)
Nursing Interventions
(Nursing initiated actions based mostly on the medical plan of care and consumer outcomes)
(Reasons why every intervention is predicted to work; connect with nursing principle, pathophysiology, APA cited)
(Expected Outcomes achieved? Not achieved?
What is subsequent? Future plan)
The Nursing diagnostic is finished based mostly on the nursing assessments obtained from the lab values. The affected person has varied indicators and signs comparable to her ache scale is 8 out of 10. The coronary heart charge is 122, present blood strain is 165/56, and oxygen stage is 99% in SPO2. Goals:

  • The affected person will again half her bodily energy by 50% when she finishes all her full remedy inside one yr as a result of she already has a damaged hip.
  • The affected person will regain her restful sleep inside a interval of 1 month after following sleep hygiene as a result of she has sleep insomnia.
  • The applicable nursing intervention entails {that a} nurse should direct the affected person to stroll by holding her hand or offering her with strolling crutches.
  • The different intervention for insomnia is coaching the affected person about rest, stimulus management remedy, sleep restriction remedy, sleep hygiene and cognitive restructuring amongst different approaches.
Provision of nursing intervention will help the consumer to get better quick. Research reveal that nursing interventions are actions taken by medical practitioners comparable to nurses as a part of a healthcare workforce to supply a secure scientific facility for all sufferers, comparable to following procedures to lower consumer an infection charges throughout the hospital keep. Evaluation of the affected person:

  • After one yr, the affected person might be examined whether or not she is ready to work correctly with out the assist of crutches. The desired end result could have been achieved after the affected person has regained her capability to again half to her bodily energy after finishing her remedy periods.
  • The sleep conduct of the affected person might be evaluated after one month. the place the affected person could have much less sleep criticism, have enough alternative for sleep, and daytime dysfunction. However, if the affected person studies hassle sleeping for aa interval of 7-8 hours however doesn’t have daytime penalties, then the consumer won’t have recovered.


Kera, T., Kawai, H., Hirano, H., Kojima, M., Watanabe, Y., Motokawa, Okay., Fujiwara, Y., Ihara, Okay., Kim, H., & Obuchi, S. (2019). Definition of respiratory sarcopenia with peak expiratory movement charge. Journal of the American Medical Directors Association, 20(8), 1021-1025. Web.

Pedersen, S. S., Von Känel, R., Tully, P. J., & Denollet, J. (2017). Psychosocial views in heart problems. European Journal of Preventive Cardiology, 24(3_suppl), 108-115. Web.

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Wynarczuk, Okay. D., Hadley, D. E., Sen, S., Ward, J. F., Ganetsky, V. S., & Sen, S. (2019). Pharmacy, bodily remedy, occupational remedy, and doctor assistant skilled college students’ views on interprofessional roles and duties. Journal of interprofessional care. Web.

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