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S: Rose Senters, age 71-year-old female B:

S: Rose Senters, age 71-year-old female B: She is a previously healthy woman who lives in a condo with her husband in Winnipeg, she has 2 kids and grandchildren who are supportive. She has history of hypertension for which she is on medications and suffers from insomnia. She fell at her condo and states she slipped in some water on the kitchen floor and that she did not hit her head. She was on the floor for about 3 hours or so, her husband came home and called the ambulance. A: She is alert and orientated to person, place, and time. Her pupils are reactive to light and she has minimal pain at this time. Vital signs are normal, BP 98/75, P 85, RR 22, SOP2 98% on RA. Pulses are palpable, she has a bruise to her right knee and side of her leg. She says she is not in any pain at this time. R. We should follow through with a complete pain assessment. CARE PLAN TEMPLATE Nursing Diagnosis/Priority Problem: Goal 1 Form Assessment Data/ Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) Client Outcomes (SMART: specific, measurable, achievable, realistic and time specific) Nursing Interventions (Nursing initiated actions based on the medical plan of care and client outcomes) Rationale/Evidence Based (Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) Evaluation (Expected Outcomes achieved? Not achieved? What is next? Future plan)

 
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