Nursing Care Plan Template Report 2022

Winter 2020 PNUR125 Nursing Care Plan Template
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Student Name: Cintia Moraes
Student Number: 301034838
Clinical Instructor: Esther
Case Summary and Client Information* (age, gender, past medical history, admitting diagnosis, allergies)
The patient is a 64 years old male with admitting diagnoses of diabetes, CHF, Hypertension, Sensorimotor
Neuropathy, Paraplegia and diabetes. Patient is allergic to Ace inhibitors, tetracyclines, sulfa (sulfonamide
antibiotics). Patient has a full code status. Patient is waiting for a long-term care facility. Patient has a past
medical Hx of HF, hypertension, obesity, chronic low back pain, pulmonary embolism, acute perforated
appendicitis, dyslipidemia, hyperkalemia, venous insufficiency, stasis dermatitis, severe neuropathy right
foot drop, retinopathy/decreased vision, hemorrhage right eye-now blind, cataract surgery left eye,
thrombocytopenia, lumbar degenerative disc disease, deep vein thrombosis, paraplegia, urinary retention,
sacral decubitus ulcer, sensorimotor neuropathy, benign prostatic hyperplasia.
Medication History
Medication Name Classification Action Indication (Reason for patient
taking the medication)
Acetaminophen Nonnarcotic,
Analgesic, Antipyretic
This medication is used for
fever reduction. It provides
temporary analgesia for
mild to moderate pain.
The reason the patient is
taking this medication due to
the chronic low back pain.
Apixaban
Anticoagulant,
Antithrombotic
This medication has no
direct effect on platelet
aggregation, but by
inhibiting factor Xa, it
indirectly decreases clot
Patient is taking this
medication to CHF, DVT. Due
to the severe neuropathy and
paraplegia patient is
immobile which cause a
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*No Patient Identifiers due to Confidentiality Reasons

Winter 2020 PNUR125 Nursing Care Plan Template
formation induced by
thrombin.
deficiency on blood
circulation This medication
will prevent clots and
possible stroke.
Dutasteride (antiandrogns)- S-
Alpha Redutase
inhibitor.
The medication will
decrease the production of
testosterone in the prostate
gland.
The patient takes this
medication due to the benign
prostatic hyperplasia. It will
help reduce the size of the
enlarged prostate.
Furthermore, improving the
urinary flow since the patient
has a history of urinary
retention.
Furosemide Electrolytic and water
balance agent; Loop
Diuretic;
Antihypertensive
Rapid-acting potent
sulfonamide “loop”diuretic
and antihypertensive.
Inhibts reabsorption of
Sodium and chloride
primarily in loop of Henle
and also in proximal and
distal renal tubules.
The patient has CHF what
may increase the blood
pressure, the patient has a
history of hypertension. This
medication will decrease
edema and intravascular
volume, which lowers blood
pressure.
Gabapentin Anticonvulsant;
Painful neuropathy
Control certain types of
seizures in the patient with
epilepsy. Efficient in
controlling painful
neuropathies.
Patient take this medication
to control the pain caused by
his sensorimotor neuropathy.
Ipratropium Nasal spray,
anticholinergic,
antimuscarinic,
bronchodilator
Produces local, site specific
effects on the larger central
airways including
bronchodilation and
prevention of
Used to bronchodilation the
air ways of the patient.
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*No Patient Identifiers due to Confidentiality Reasons

Winter 2020 PNUR125 Nursing Care Plan Template
bronchospasm.
Irbesartan Angiotensin II
receptor antagonist,
antihypertensive
This medication blocks
vasoconstricting and
aldosterone-secreting
effects of angiotensin II,
thus resulting in an
antihypertensive effect.
Since the patient has a
history of hypertension and
CHF. The medication will
make that the blood flows
better in the arteries
decreasing the BP.
Isosorbide Dinitrate Nitrate vasodilator Has an antianginal effect as
a result of vasodilation of
the coronary arteries.
Patient is taking this
medication because of CHF
and his hypertension
problem. Narrowed artery in
the heart or high blood
pressure, progressive leave
the heart too week or stiff to
fill and pump.
Lactulose Hyperosmotic
laxative, Neurologic
Osmotic effect of lactulose
moves water from the
plasma to intestines,
softening stools, and
stimulates peristalsis by
pressure from water
content of stool.
The patient is immobile
causing the decrease of
peristalsis movement in
consequence the patient
presents constipation. This
medication will help on BM.
Linagliptin Hormone modifier,
Antidiabetic, Incretin
modifier, Dipeptidyl
Peptidase – 4 Inhibitor
When the blood glucose
begins to rise, incretin
hormones stimulate insulin
secretion and reduce
glucagon secretion,
resulting in decreased
hepatic glucose production.
Patient is taking this
medication because he has
diabetes this medication will
decrease the glucose levels
on the blood.
Melatonin Neurology and Can be used to treat
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*No Patient Identifiers due to Confidentiality Reasons

Winter 2020 PNUR125 Nursing Care Plan Template
Psychiatry, Herbals delayed sleep phase and
circadian rhythm sleep
disorders in the blind and
provide some insomnia
relief.
The patient takes this
medication to have a better
sleep.
Metformin
Antidiabetic;
Biguanide
Supresses gluconeogenesis
and hepatic production of
glucose. Effective in
lowering serum glucose
levels.
Patient is taking this
medication because he has
diabetes this medication will
decrease the blood sugar
levels on the blood.
Pantoprazole Sodium Gastric Proton Pump
Inhibitor;
Antisecretory
Supresses gastric acid
secretion by inhibiting the
acid (Proton H+) pump in
the parietal cell.
The patient is taking this
medication for heartburn.
Polyethylene Glycol Laxative solution It works by causing water
to be retained with the
stool. This increases the
number of bowel
movements and softens the
stool.
The patient is immobile
causing the decrease of
peristalsis movement in
consequence the patient
presents constipation. This
medication will help on BM.
Senna Glycosides Stimulant Laxative Senna glycosides are
converted in the colon to
active aglycone, which
stimulates peristalsis.
This medication will help with
his BM.
Silodosin Alpha-1 Adrenergic
Receptor Antagonist;
Genitourinary Smooth
Muscle Relaxant
Selective antagonist of
post-synaptic alpha-1
adrenoreceptors located in
the prostate, bladder base,
bladder neck, prostatic
capsule, and prostatic
Since the patient has BPH he
has difficulties to urinate.
This medication will cause
the smooth muscle to relax
resulting in improvement of
urine flow and reduction of
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*No Patient Identifiers due to Confidentiality Reasons