can someone please help me out? I would like to know if I did ok on this careplan,
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am I missing anything?
It does not seem right?
Please take a look
age 88
room 8769087
admission date 01/01/1817
medical diagnosis RT kneee replacement
Treatment for pain tylenol PRN with rest
baseline vitals
Temp 35.4
pulse 82
oxygen sat 93%
BP sitting 146/68
weight 81.82
Hygiene
Lotion to back & heels
Clotrimazole cream to perineum area
Bath
assist
glasses, hearing aid, upper and lower dentures
Mobility
fear of falling and getting seriously hurt
at risk for falls
1 person assist
Activity order
painful to lift right leg straight, assist with arm strengh
Mobility devices
assist with ADL & mobility
4 WW, cane, grab bar
Hard of hearing
Allergies
penicillin, sulfa, erythromycin, and possibly milk
previous medical/surgical Hx
hypothyroidism, anxiety, diverticulitis,(bilateral caterac surgery), cholecystectomy, cystoscopy, hypothyroidism, urinary incontinence, constipation, B 12 deficiency, diverticular diseases an element of COPD, anxiety, catherization
Treatments
physiotherapy, GRU, urology
Rehab/physio
Recent diagnostic tests
Coagulation
INR * 2.6 H 0.8 - 1.2 electrolytes NA 136 K 4.0 Cl 99 l
Co2 -29
urea 3.9
Nutrition
Regular
Elimination
uses commode at night
Last BM
may 22/19
bowel care order
Urination
incontinent
requires catheter
Indwelling catheter
size #14
last changed
q6h or keep foley in permanently change every month
incontinent (requires catheter)
Please can you help me do the nursing interventions?
Thank you :typing