Patient and Family Care Plan

PATIENT AND FAMILY CARE PLAN FORM Date: Assessment Primary and secondary data ______ Time Plan: Nursing Diagnosis Name/Course ___________________________ Intervention Evaluation _______ Revisions SAMPLE PATIENT #1 –B.G. DEMOGRAPHICS: AGE-62 DOB-1/29/54 MARITIAL STATUS-DIVORCED CHILDREN- 2 GROWN (BOY ANG GIRL) WITH 4 GRANDCHILDREN RELIGION-BAPTIST Homeless ADMISSION HISTORY AND PHYSICAL CHIEF COMPLAINT: draining left thigh wound HISTORY OF PRESENT ILLNESS: patient sustained a gunshot wound to left thigh in 1992. plate became loose likely secondary to infection in 1999. he was treated with antibiotics and the wound allowed to heal by secondary intention. wound intermittently underwent breakdown and drainage in 2014 following stress put on leg when patient stood for long hours. Plastic surgeon didi a culture and found it was infected and e=recommended a debridement which was done July 15. He was discharged on pain killers and antibiotics. ID saw patient in August 2016 per his Plastic surgery’s recs and determined that stronger IV antibiotics would be required. PAST MEDICAL HISTORY: Hypertension Acid reflux Osteoarthritis Gout FAMILY HISTORY: Hypertension in mother PERTINENT MILITARY HISTORY: US Army Communications Specialist 4th Class SOCIAL HISTORY: Bus Driver for First transit ALCOHOL USE HISTORY: Stopped 15 years ago TOBACCO USE HISTORY: Stopped about 15 years ago MEDICATION RECONCILIATION: Medication reconciliation was done from the following sources to develop a complete and accurate list of medications the patient is currently taking: Other Outpatient medication list Current Active Outpatient Medications: Ciprofloxacin Hcl 500mg Tab Take One Tablet by Mouth Twice A Day for Infection Oxycodone 5mg/Apap 325mg(Percocet) Take 2 Tablets by Mouth Every Four Hours As Needed Omeprazole 20mg EC Cap Take One Capsule by Mouth Every Day for Stomach Cyclobenzaprine Hcl 10mg Tab Take One-half Tablet by Mouth Twice A Day for Muscle Spasm Amlodipine Besylate 5mg Tab Take One Tablet by Mouth Every Day Atenolol 50mg Tab Take Two Tablets by Mouth Every Day Gabapentin 300mg Cap Take One Capsule by Mouth Three Times A Day Hctz 25/Triamterene 37.5mg Tab Take 1 Tablet by Mouth Every Day Polyvinyl Alc 1.4% Oph Soln (Art. Tears) Instill 1 Drop In Each Eye Four Times A Day for Dry Eyes Sildenafil Citrate 100mg Tab Take One Tablet by Mouth 30 Minutes Before Activity 30 Minutes Before Sexual Activity. No More Than 4 Doses Monthly. Lost or Stolen Prescriptions Will Not Be Replaced. Patient and Family Care Plan

0mcg (Cfc-f) 200d Oral Inhl Inhale 1 or 2 Puffs by Mouth Every Six Hours As Needed for Breathing or Shortness Of Breath Colchicine 0.6mg Tab Take One Tablet by Mouth Every Day Take 2 Tablets On Day #1, Then 1 Tablet Daily Until Gone Ibuprofen 400mg Tab 400mg by Mouth Every Day Immunizations: Last PNEUMO-VAC Vaccine Nov 02, 2004@10:30 Last INFLUENZA Vaccine OCT 22, 2015@10:10 No skin tests found. ALLERGIES & SENSITIVITIES: SHELLFISH REVIEW OF SYSTEMS GENERAL: Pain: Yes, describe: Location: left thigh Intensity and character: dull Duration: constant Response to treatment: good EYES/VISION: EARS/NOSE/THROAT: RESPIRATORY: Exposure to TB: No CARDIOVASCULAR: 1st and 2nd heart sounds GASTROINTESTINAL: soft non tender BS normactive GENITOURINARY: High risk sexual behavior: No ENDOCRINE: SKIN: intact MUSCULOSKELETAL: NEUROLOGICAL: alert awake oriented X3 PSYCHIATRIC: Are you having feelings of hopelessness for the present and the future? No PHYSICAL EXAMINATION BP: 108/68 (08/18/2016 17:38) PR: 61 (08/18/2016 17:38) RR: 20 (08/18/2016 17:38) T: 98.6 F [37.0 C] (08/18/2016 17:38) 8/18/16 @ 1738 PULSE OXIMETRY: 95 8/18/16 @ 1313 PULSE OXIMETRY: 97 8/18/16 @ 1034 PULSE OXIMETRY: 96 Weight: 220.5 lb [100.2 kg] (08/12/2016 10:42) BMI:34* GENERAL APPEARANCE & MENTAL STATUS: Head: Eyes: PERRL Ears: Nose: Mouth: Moist mucosa Teeth: Neck/Throat: supple Chest: CTAB Heart: S1 S2 Breasts: Lungs:CTAB Abdomen:soft non tender Genitalia:normal Female: Pap smear done: Rectal: Occult blood: negative Decubitus ulcer location (sacrum, heel, occiput or other: Stage:None Male: prostate: Back/Spine: Skin:Intact Extremities: Lymphatics: Neurological: DIAGNOSTIC TESTS Lab Values: WBC: 8.3 K/cmm 8/18/2016@15:56 blood RBC: 3.3 Mil/cm 8/18/2016@15:56 blood HGB: 12.0 g/dl 8/18/2016@15:56 blood HCT: 34.6 % 8/18/2016@15:56 blood PLT: 302.0 K/cmm 8/18/2016@15:56 blood NA: 134.0 mmol/L 8/18/2016@16:55 serum K: 3.7 mmol/L 8/18/2016@16:55 serum CL: 97.0 mmol/L 8/18/2016@16:55 serum C02: 28.0 mmol/L 8/18/2016@16:55 serum BUN: 6.0 mg/dl 8/18/2016@16:55 serum Creatinine,Serum 1.1 mg/dl Aug 18, 2016 GLUCOSE: 103.0 mg/dl 8/18/2016@16:55 serum HGBA1C: 6.1 % 5/9/2016@12:12 blood CHOL: 188.0 mg/dl 5/9/2016@11:44 serum ^@@^HDL-DATE/TIME HDL-CHO: 40.0 mg/dl 5/9/2016@11:44 serum LDL: 127.0 mg/dl 5/9/2016@11:44 serum CA: PO4: MG: 9.8 mg/dl 4/16/2013@12:16 serum 3.3 mg/dl 4/16/2013@12:16 serum 1.8 mg/dl 4/16/2013@12:16 serum Liver Functions: PROTEIN: 7.7 g/dl 8/12/2016@14:01 serum ALBUMIN: 3.2 g/dl 8/12/2016@14:01 serum SGOT: ALT: 28.0 Units/ 8/12/2016@14:01 serum 20.0 Units/ 8/12/2016@14:01 serum ALK PHO: 125.0 mU/ml 8/12/2016@14:01 serum T. BIL: 0.6 mg/dl 8/12/2016@14:01 serum BILIRUBIN, DIRECT: 0.2 (8/12/2016) SERUM Coagulation No PT found within 6 months INR 1.1 Ratio Aug 18, 2016 PTT 30.5 sec. Aug 18, 2016 EKG: XRAYS: : Not Found DIAGNOSTIC IMPRESSION: PLAN: VTE PROPHYLAXIS: Pharmacologic indicated. Medical Patients: Heparin 5000 units SQ q8hrs ADVANCED DIRECTIVES: wants further information Patient informed about the diagnostic and treatment plans and expresses understanding. Compared newly ordered medications and medication changes to active medications and non-VA medications, and then reviewed medications with patient/significant other/designated caregiver. New medications today: No (Refer to orders in CPRS for changes in medications) Medications discontinued today: No _____________________ PHYSICIAN/HOSPITALIST Patient and Family Care Plan