CARE PLAN

Running head: NAME OF CARE PLAN 0

Title of Plan of Care

Name

South University Online

Faculty Name

NSG 6001

Date

Patient Initials __AM____

Subjective Data: Patient reports sates has been lightheaded, felt palpitations of his heart, and shortness of breath the last 2 days. States has previously felt the palpitations associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away but they have continued and that is why he is here today.

Chief Compliant: 52 years old male status post stent placement 2 weeks ago presenting for follow up with chief complaint of lightheadedness, palpitations, and shortness of breath for 2 days, not relieved by rest.

History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).

Review of Symptoms: (Review each body system - This section you should place POSITIVE for… information in the beginning then state Denies…). - General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data:

Vital Signs: BP - ; P ; R ; T ; Wt. ; Ht. ; BMI .

Physical Assessment Findings: (Includes full head to toe review)

HEENT:

Lymph Nodes:

Carotids:

Lungs:

Heart:

Abdomen:

Genital/Pelvic:

Rectum:

Extremities/Pulses:

Neurologic:

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).

References

Definition: 'Android Obesity' (nod). Retrieved from http://www.medilexicon.com/medicaldictionary.php?t=62022

Drugs.com. (2016). Aspirin - FDA prescribing information, side effects and uses. Retrieved from https://www.drugs.com/pro/aspirin.html

Drugs.com. (2016). Atorvastatin - FDA prescribing information, side effects and uses. Retrieved from https://www.drugs.com/pro/atorvastatin.html

Drugs.com. (2016). Bupropion: MedlinePlus Drug Information. Retrieved from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a695033.html

Drugs.com. (2016). Tenormin - FDA prescribing information, side effects and uses. Retrieved from https://www.drugs.com/pro/tenormin.html

Mayo Clinic. (2015). Heart disease. from http://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-healthy-diet/art-20047702