Aspen University Fundamental in Nursing II Conceptual Care Map

Description

Complete a Modified Conceptual Care Map regarding the following case study.

T.L. is a 59-year-old female admitted to the med/surg unit following a fall at home. The client tripped over her cocker spaniel and suffered a fractured right humerus. Client also has 1 cat. The fracture was surgically repaired with an ORIF (Open Reduction, Internal Fixation) 16 hours previous to your coming on shift. T.L. has her right arm remains in the surgical splint placed by the orthopedic surgeon and is wearing an arm/shoulder immobilizer.

Past Medical & Surgical History:

Appendectomy at age 15 years

Hysterectomy 8 years ago

Hypertension

Family History:

Mother died of breast cancer at age 50.

Sister died of breast cancer at age 55.

Father died of heart attack at age 65.

No children

Social History:

Divorced, lives alone, house in Tempe

Smoker (1/2 pack per day)

Social drinker (states less than 3 drinks/week)

Catholic – practicing, attends mass regularly

Patient is right-handed

Allergies:

Penicillin

Home Medications:

Aspirin 81 mg po daily

Multivitamin po daily

Atenolol 50 mg po daily

HCTZ 25 mg po daily

Premarin 0.625 mg po daily

Tylenol 1000 mg po prn headache

Ibuprofen 800 mg po prn “aches and pains”

Hospital Provider Orders:

Regular diet

Encourage to be OOB

Physical Therapy consult and treat

Occupational Therapy consult and treat

Vicodin 5/325 1-2 po every 6 hours prn pain

Continue home medications as noted above

IV Saline Lock with routine flushes

Lovenox 40 mg Subcutaneously daily for 14 days

Vancomycin 750 mg IV q 12 hours for 5 days

CBC, BMP, PTT, PT/INR in morning

Vanco peak and trough with third dose

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