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Mark Johnson is a 65 year old male who has been admitted to your care with a diagnosis of
Pneumonia, secondary to Debilitation from recent contraction of COVID-19. The patient is negative for
COVID-19 at this time and is at your facility for rehab and strengthening.
Health History: COPD, Morbid obesity, CHF, and Sleep Apnea
Surgical History: Lumbar fusion of the L2-L3, Cardiac Catheterization with 2 stents placed
Hardware: Tracheostomy, PICC line, G-tube
Skin Assessment: Fungal rash in inguinal area, Stage 4 pressure ulcer with tunneling to right buttocks
Labs: WBC-15.3, Hgb-10.3, Blood sugar-109, BUN-21, urine creatinine-1.83, K+-4.3, Na+-133
Vitals: BP-106/60, HR-96, RR-20, Temp-99.1 degrees, O2 sat-88% with 2L nasal cannula, Weight 345 lbs.
Medications: Tylenol 650 mg PO PRN, Hydrocodone 5/325 mg PO PRN, Ipratropium bromide TID
nebulizer, Enoxaprin 40 mg subcutaneous Daily, Metoprolol 50 mg PO BID, Clopidigril 75 mg PO Daily,
Docusate 100 mg PO BID, Vancomycin 1250 mg IV BID
The patient is unable to bear his own weight. The patient also had an episode of oxygen
desaturation the prior evening and needed to be placed on his Bi-Pap on 6L in order to maintain O2 Sat
of 94%. He is currently wearing his nasal cannula on 2L.
Your directions are to write the pathology for the diagnosis. Then write a care plan for the patient in
paragraph form with 5 nursing diagnosis and 5 nursing interventions with rationales, and goals and
planned outcomes. List the potential subjective and objective problem areas you might expect to find
related to his diagnosis and health history. This will help find your nursing diagnosis. You will write out
an assessment of the patient in paragraph form. The best way to go about this would be to look into
your fundamental book or practice sheet you got in lab for check-offs. Explain the maintenance of the
hardware section. Explain what you would expect to do about the skin assessment and detail the type of
wound care you might give. Explain what each of the labs would be evaluated for and if they present
you with any issues to think about with their current values. Also, write what each medication is used
for and why your patient might be taking them given his current situation.
This should be written in a 5 page double spaced format minimum. Also, list any sources you may use.
This should be enough information in the directions to help guide you along the way. Email us if you
have any questions. Get detailed and make it fun.