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professional cae plan
its a case scenario of a patient with a nursing care plan and intervention
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1 Nursing Care Plan Group 4Mark Angelo Ferrer – 122460207
Harpreet Kaur – 142180207
Muskan Thakur – 166559195
Navjot Kaur – 107268203
Puvneet Kaur – 143830206
Seneca College CDM 102KAA: Professional Practice Standards
Professor Lisa Garraway
December 3, 2021
2 Nursing Care Plan
Biographical Data: Patient name: Not available Gender: Male Age: 87 years History: Chief
complaints:Patient came to his primary care practitioner with the chief complaint of falling down
frequently at home due to leg weakness and visual difficulties. History of present illness:Patient has
chronic obstructive pulmonary disease (COPD), and a recent diagnostic test indicated that he has
moderate cerebral atrophy and glioblastoma multiforme (GBM). Past medical and surgical
history:Patient has a Diabetic Mellitus medical history but no surgical history. Current medications and
, treatment:Patients under the hospice care after getting diagnosed with gliuoblastoma mutliforma.
Assessment data: System data collection: Nervous system: • Orientation: patient is well oriented to his
surroundings • Mental status: conscious • GCS Scale: no data provided • Communication and hearing:
He's speaking effectively as he explains the issues he's having and hearing is good. • Vision: He has visual
problems, as he stated that he repeated crawling around the house to get around. Respiratory System: •
Respiration rate: 16 per minute • SPO2 level: 96% • Cough: no data found • Secretions: no data found 3
• O2 therapy: no data found Musculoskeletal system: • Weakness in his lower limbs noted • He needs
assistance because he can’t walk and transfer independently Cardiovascular System: • Pulse rate: 88
beats per minute, normal • Blood Pressure: 132/80 mmHg • Capillary refill: normal Psycho social: • He
was with a family member in the beginning of his treatment Pain: Although no pain sensations are noted
in the scenario, the patient does have lower limb weakness, which limits his movement. Lab and
diagnostic test Reports: • CT scan: the results revealed significant cerebral atrophy as well as a poorly
defined 1.5 cm lesion overlying the superior portion of his left lateral ventricle in the corona radiata
region, with minor vasogenic edema. • MRI: indicated more heterogeneous lesions in brain. • Brain
biopsy: Diagnosed him with glioblastoma multiforme Head to toe physical assessment: Assessment
Findings • Skin Skin pinched it goes to previous state • Skull Rounded and symmetrical • Eyes and Vision
Visual difficulties as patient verbalized, he had difficulty in moving around • Mouth and oropharynx
Normal, symmetrical • Muscle strength Weakness as patient had difficulty in moving his lower limbs. •
Breath Sounds Normal breath as respiration rate is 16 breaths 4 per minute • Abdominal movements
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