Client s Name A Short Note On Diabetes, Type II...

Client’s name is C.H. she is a 45-year-old women who was admitted on August 15, 2016 for a right knee replacement with alcohol intoxication who was currently going through delirium tremens (DTs). Past medical history included hypertension, type II diabetes and alcohol abuse. The most pertinent relevant family/social factors about this patient was the fact that she has a history of physical abuse from her past boyfriend and a history of abuse with alcohol. This was a vital piece of information that helped to mold care for the patient. This patient was chosen due to the fact that the interaction of the patient was one that has not been previously explored during other clinical rotations and changed my overall perception on how patients should be treated. The Nursing Process Assessment The body systems that were assessed on this patient was examined utilizing a focus assessment. The patient’s primary diagnosis for being admitted to the Post-Surgical unit was for a knee replacement. First assessment was general appearance and mental status. C.H. was alert orient x2. She was aware of self, but not oriented to place or reasoning why she was hospitalized. Patient would constantly have asked, â€Å"Are my dogs with me?† â€Å"Did you feed the dogs before you left?† During the patients stay, a Code Silver called on her, which indicated violent tendencies. Fortunately, patient was receptive and appropriate during shift. A0 x3- oriented to person, place, time and situation. Pupils round,Show MoreRelatedNursing Care Plan Essay10501 Words   |  43 PagesNursing Care Plan CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for atypical chest pain and hemoptysis. V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . 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