Patient Information and Care Plan Essay

Date of Assessment:
It is difficult answering these questions because the available data only indicates Evelyn’s date of birth, her weight, and height during the time of admission to the hospital.

Allergies

It is evident from the case study that Evelyn takes Tylenol. This is an acetaminophen medicine for headaches also sometimes accompanied by sinuses allergy. An allergy headache activates sinus or nasal congestion which is the reason why the patient takes ibuprofen and Tylenol. Some types of pain relievers such as Tylenol which is a mild over-the-counter ibuprofen or pain reliever may offer short-term relief for sinus headache pain.

Social History

The social history comprises all aspects of the family of the patient, and medical history, and other information that is relevant to the occupation, religion, race, and life events of the patient.

Summary

• Family: Evelyn is married with two grown sons.
• Medical History: The patient has previously identified with breast cancer (stage IV), chronic insomnia, osteoarthritis (knees, hips, and hands), and chronic low back pain.
• Occupation: Retired teacher
• Note: It is important to note that life the religion, race, and life events of Evelyn were not indicated in the data that was provided.

Supports

Evelyn receives most of the support from her husband, her two grown sons, doctors, and nurses

• First, it is important to identify the patient’s presenting problem
• Presenting problem of the patient:the patient has a broken hip
• Signs and symptoms:the patient has chronic low back pain, tired dark circles under her eyes, and often experience difficulties when sleeping.
• Onset:within the past three days

• Morphine 2-5 mg IV q4hr Tylenol Extra Strength 1-2 tabs Q4hr PRN for Pain.
• Multi Vitamin PO QDaily Ibuprophen 200-400mg Q6hr PRN for Pain.
• Vitamin D 1,000 is daily Boniva 1-tab every month on the 8th day of the month.

• The patient will back half her physical strength by 50% when she finishes all her full therapy within one year because she already has a broken hip.
• The patient will regain her restful sleep within a period of one month after following sleep hygiene because she has sleep insomnia.

• The appropriate nursing intervention entails that a nurse ought to direct the patient to walk by holding her hand or providing her with walking crutches.
• The other intervention for insomnia is training the patient about relaxation, stimulus control therapy, sleep restriction therapy, sleep hygiene and cognitive restructuring among other approaches.

• After one year, the patient will be examined whether she is able to work properly without the support of crutches. The desired outcome will have been achieved after the patient has regained her ability to back half to her physical strength after completing her therapy sessions.
• The sleep behavior of the patient will be evaluated after one month. where the patient will have less sleep complaint, have adequate opportunity for sleep, and daytime dysfunction. However, if the patient reports trouble sleeping for aa period of 7-8 hours but does not have daytime consequences, then the client might not have recovered.