Care Plan



Patient Initials: __ Age: 65 years___ Sex:_Female__

Subjective Data:

ClientComplaints: Cough for two weeks, particularly dry cough, low gradefever two days. Reduction in appetite levels, slight sore throat inthe morning, has a feeling of probably having lung cancer.

HPI(History of Present Illness):

Havehad prolonged fever as well as increased level of dry coughs and sorethroats.

PMH(Past Medical History—include current medications, any knownallergies, any history of surgery or hospitalizations):

Currently,the patient takes no prescription medicines. She takes occasionalover-the-counter Tylenol for pain. The prescription is Tylenol 650mg, 2PO as required.

In thepast, she has been treated for the problem using antibiotics andinhalers. Notably, she has never been hospitalized. Had the chestinvestigated the last encounter she had with the problem. Pastexamination, shows that the patients did not have pneumonia ratherhad emphysema. Had asthma as a child and in 1970s, she hadhysterectomy. The patient is allergic to sulfa drugs that cause rash.

Significant Family History:

Social/Personal History (occupation, lifestyle—diet, exercise,substance use)

The patient is a Cigarette smoker. She has been a widow for 2 decadesnow and every years gets pension of $40000. She has been saving partsof income. She is learned and has a diploma and owns a house. With asmall chunk of disposable income, she is managing her finances. Sheseems to be a bit ignorant in regards to the various communityresources in her environment. Has a primary care provider whoprovides care to her every quarter of the year. The care entailsphysical examination. She has insurance cover though it does not meetall her bills. She is mother to two daughters who are elderly andstay in adjacent neighborhood. The daughters are in their forties andare doing well. She is not social and this can be a source ofdepression to her. The patient suffers from reduced levels of dailystress. She is a church-goer and every month she visits thedaughters.

Description of Client’s Support System:

Even though the church and the daughters are the support system, thepatient does not relate to them daily.

Behavioral or Nonverbal Messages: Keeps healthy diet does not admitto smoking and drinking.

Client Awareness of Abilities, Disease Process, Health Care Needs:

Objective Data:

Vital Signs including BMI: From the client it was found that theyincluded 130/72 leftarm sittingregular cuffT: 101po P:100 andregular R:20, non-laboredWt: 130#Ht: 55”.Notably, for this client some of the things that were not examinedinclude rectum, genital, and neurologic.

Physical Assessment Findings:

Lab Tests and Results:

The client had the following lab tests and the results were asfollows. For the CBC- WBCs15, 000with +left shift whilefor the Pulse oximeter,the reading was SAO2:98%. For the CXR, the results were same as that of x-ray. TheEKG test revealed that the sinus rhythm was normal.

Client’s Support System: Church and Family members

Client’s Locus of Control and Readiness to Learn: Ready

ICD-10 Diagnoses/Client Problems:

She has insurance cover though it does not meet all her bills

Advanced Practice Nursing Intervention Plan (includinginterdisciplinary collaboration, community resources and follow-upplans):

She is learned and has a diploma and owns a house. With a small chunkof disposable income, she is managing her finances. She seems to be abit ignorant in regards to the various community resources in herenvironment


Metlay, J.P., Kapoor, W. N., &amp Fine, M. J. (1997). Does this patient havecommunity-acquired pneumonia?: Diagnosing pneumonia by history andphysical examination.&nbspJama,&nbsp278(17),1440-1445.

Mills, P. K.,Beeson, W. L., Abbey, D. E., Fraser, G. E., &amp Phillips, R. L.(1988). Dietary habits and past medical history as related to fatalpancreas cancer risk among Adventists.&nbspCancer,&nbsp61(12),2578-2585.