Brain TIA nursing care plan

Brain TIA nursing care plan GRADE (NOTE: A grade of 75% or above is satisfactory) 100 FACULTY: PRAIRIE VIEW A&M UNIVERSITY College of Nursing BASIC CONCEPTS PRACTICUM – NURS 3263 DATA COLLECTION TOOL Student’s Name Giau Ta Date 11/02/2016 Biographical data Client’s initials NN Unit/Room No. 324 Age 90 Gender F Ethnicity Asian Religion Christian Marital Status Married Occupation Retired Date of Admission 10/28/2016 Admitting Problem/Diagnosis Slurred speech Brain TIA Chief Complaint (Why did the patient come to the hospital – in patient’s own words) “While I was talking with my daughter in law, my speech was suddenly slurred and the right side of my face drooped. My daughter in law knew there was something wrong happening to me so she called an ambulance. ” Past Health History Asthma N/A Emphysema N/A Bronchitis N/A Pneumonia N/A TB N/A Angina N/A MI N/A Anemia N/A Hypertension N/A Rheumatic Fever N/A Pacemaker N/A Peripheral Vascular Disease N/A Blood Disorders N/A Stroke X Skin Disease N/A Bladder Infections N/A Kidney Disease N/A Ulcers N/A DM N/A Dental Problems N/A Fractures N/A Congenital Heart Defects N/A Surgeries N/A Family Health History Condition Family Members Condition Family Members Heart Disease N/A Tuberculosis N/A Hypertension N/A Asthma N/A Stroke N/A Mental Illness N/A Diabetes N/A Alcoholism N/A Cancer N/A Kidney Disease N/A Other Health Problems in Family: N/A Medications Prior to Admission: (List) Prescription: Potassium Chloride Nonprescription: N/A Digoxin N/A Furosemide N/A Metoprotol succinate N/A Allergies and Reactions: Identify the drugs allergic to and describe the client’s response to them: No Known Abnormal Laboratory and Diagnostic Studies Please list any abnormal results that your patient had and implications related to abnormal findings. Diagnostic Study Result Implication Glucose Level 208 mg/dL (H) 70-110mg/dL Type 2 diabetes, sever stress on the body from diseases, chronic kidney failure, pancreatitis, hyperthyroidism Complete Blood Count- RBC 3.16 k/uL (L) 4.0-10.0 k/uL Implication of anemia, nutritional deficiency, chronic inflammatory disease, and kidney disease CBC-HGB 10.7 g/dL (L) 12.0-16.0 g/dL Anemia, emphysema, asthma, nutritional deficiency CBC-HCT 31.8 % (L) 36.0-48.0 % Anemia, kidney failure, nutrition deficient CBC-MCV 101 um3 (H) 78-98 um3 Kidney failure, iron-deficiency anemia, Calcium 8.0 g/dL (L) 8.5 - 10.5 mg/dL Inadequate intake, Vit D deviciency, renal failure, hypoparathyroidism Total Protein 5.6 g/dL(L) 6.0 - 8.3 g/dL Malnutrition, Agammaglobulinemia, Liver disease Albumin 2.6 g/dL(L ) 3.5-5 g/dL congestive heart failure, pericarditis other Tests or Procedures: Chest X-Rays, CT scan, Blood test, MRI, Accu-Chek