I’m working on a nursing case study and need a sample draft to help me study.
Today you are working on a subacute/rehabilitation unit. You make rounds on your
assigned patients, introducing yourself and doing a general survey of their conditions.
Mr. Cohen is new client admitted yesterday. He is a 75-year-old with a history of atrial
fibrillation and chronic obstructive pulmonary disease (emphysema). During the last
month he has lost 10 lb., weighting now 114 lb.
He reports that he has been to keep the head of his bed up for most of the day and night to
facilitate his breathing, which has resulted in chronic lower back pain. Acetaminophen
(Tylenol) was not effective in reducing his pain, so the physician has prescribed
oxycodone-acetaminophen (Percocet) 1 tablet PO every 6 hours as needed for pain.
Mr. Cohen is on two liters of oxygen by nasal cannula; his lung sounds are clear but
diminished bilaterally. He has daily orders to receive respiratory treatments with
Ipratropium TID, and albuterol every six hours as needed. He takes Coumadin and needs
someone to walk beside him when he ambulates because he has an unsteady gait and
often needs to stop to catch his breath.
1) What is included in the general survey assessment of a client? (10 points)
2) What assessments/monitoring are necessary for a client on anticoagulant therapy,
why? (10 points)
3) From the case study identify an Actual Nursing Dx (R/T, AEB), write a goal and
three interventions with textbook rationales and evaluation. (40 points)
4) Identify a Potential/Risk Nursing Dx (R/T), write a goal and three interventions with
textbook rationales, and evaluation. (40 points)
You must submit all your answers typed on a word document. Cite the resources used.
For the care plan use the template attached. Hand-written papers will not be accepted.ATTACHMENTScase_study_n101c__10.26.20_term_care_plan.docnursing_care_plan_template_p._1.docxnursing_care_plan_template_p._2.docx