Care plan

See the scenario attached and complete the care plan form template as much as possible.

  SCENARIO

Develop a care plan for this patient.

You are the nurse caring for an older adult, 85 years old, complaining of shortness of breath without any activity. The resident stated, help, I cannot breathe. She has no history of any allergies. She is a widow and practices the catholic faith. She has an advance directive do not resuscitate. Medical records indicated patient has diagnoses for chronic failure with hypoxia, peripheral vascular disease, atrial fibrillation, chronic obstructive pulmonary disease, essential hypertension, chronic kidney disease stage 3, gastro-esophageal reflux disease without esophagitis, anemia, hypomagnesemia, type 2 diabetes mellitus without complication, heart failure, pure hypercholesterolemia, abdominal aortic aneurysm with rupture.

On the day of admission, her vital signs are as follows. Alert and oriented times 2, edema plus + 2 skin integrity extremities are cold.

Bp 166/100, HR 105, R 22 Temp 96.7*, Spo2 88 %, pain level 6/10

Weight 184lbs height 68 inches BMI 26.6. Mobility: short distance with rollator walker.

Home medications

Acetaminophen oral cap 325mg tab po q 4 hours for pain.

Diltiazem hcl er extended-release 240mg.

Fish oil 1000mg cap po q daily

Furosemide 20mg tab po q daily

Losartan potassium 50mg po q daily

Magnesium oxide 250mg Tb po q daily

Metformin 1000mg tab po q bid AM and EVENING.

Metoprolol succinate 50mg tab po q daily 

Omeprazole 20mg po q daily 

Potassium chloride 20meq tab po q daily 

Simvastatin oral 40mg tab po daily at bedtime