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John A  is an 88 year male. He had surgery on his hip (hip replacement) recently. Carl has returned to his long term care home. His would from the surgery is not healing, it is draining and causing him lots of pain.

John A has had  delirium episodes as well as frequent UTIs.

He became incontinent and depressed.

 

Medications; Metformin, Lipitor, Amlodipine, Macrodantin

 

 

Research of 3 priority diagnosis
Research ALL client medications prior to care
Client data information prior to care
Physical assessment data after completing client assessments
Priority problem list based on identified client care needs (priority problem must have 4 interventions including rationale to address the problem)

Sample documentation.

 

SCIENCE
HEALTH SCIENCE
NURSING
PNC 220