Pt. name:  Juan Manuel                          Admitting Physician:   Dr. Cane        
Age:64                                            DOB:1/27/1949                             
Admitting diagnosis: CHF, COPD
Pt. ID # 542768                                                Med Rec #:  78543
Wt. lbs: 200    kg: 90.9                  Ht.: 5 ft  2 in                                 Race:American- Hispanic
Major Support:  wife                                                                     Religion:Catholic

Immunizations: not current
Allergies: NKDA

 

 

 

 

 

Physician Orders
History and Physical
Physician Progress Notes
Graphics/I&O
Laboratory
Diagnostics
Procedures/Surgeries
Medication Record
Nursing Assessment
Nursing Notes
Complete Patient Assessment
Return to Patient Index
Return to Unit Index


#1 Priority Impaired Gas Exchange re: __
Expected Outcomes:
02 sat will be greater than 90 on 3 liters NC this shift
Respiratory rate will be greater than 12 and less than 22 this shift
WBC will decrease to 16,000 this shift

Assessments:
anxiety and restlessness
02 sat
Resp. rate, characteristics, effort
lung sounds
cough/sputum - coca
skin color/cyanosis
shortness of breath with exertion
cap refill
heart rate/ rhythm
WBC
ABGs
CXR

Treatments:
CXR - PA/Lat
SpO2 q4 hrs and PRN
O2 to keep O2 sat greater than 90 per O2 protocal
auscultate lung sounds q4 hrs and PRN
TCDB
HHN
Sputum - Gm stain, C&S
VS q4
CBC/WBC
BR with BRP (because short of breath with any activity)
DVT prophalaxis, CBC(PLTS),PT/INR, &PTT because on BR with BRP
elevate HOB
Increase fluids
cluster care

Medications:
Oxygen
Xopenex
Azithromycin
ceftriaxone
guaifenesin
Lovenox

Influenza vaccine
Pneumonia vaccine
Teaching:
Need for O2
IS use
importance to CDB
Limited activity - BR with BRP
HHN use
Need for sputum sample
Need to complete ABX
Increase Fluid intake

#2 Nausea re:
Expected Outcomes:
Will be free from any nausea/vomiting this shift
Will tolerate 720ml po intake without nausea/vomiting this shift
Will tolerate 50% of meals - regular diet without nausea/vomiting this shift

Assessments:
VS - orthostatics
nausea
skin turgor
oral mucosa
things that cause nausea
po intake
urine output - coca
abdomen appearance, bowel sounds
nausea re: to coughing
food preferences
s/s of fluid volume deficit
abdomen - pain, distention, bowel sounds, bowel habits
UA
electrolytes
Treatments:
quiet environment
cool washcloth
provide small frequent feedings of patient's choice
remove cover from meal tray before entering room
I&O
dietary consult - diet as tolerated
BMP
UA

Medications:
Zofran
Protonix

Teaching:
Need to record input and output
try small amounts PO frequently
notify the nurse when nauseated
#3 Risk for Social Isolation re: No family/friends in area - new to area, new job

Assessments:
Affect
Support system in area
Friends available to help when discharged if needed
Ability to communicate with family and friends
available transportation and knowledge of navigation in new area (location of pharmacy, Dr. office, public transportation)

Treatments:
offer self - schedule time to sit with client
listen to verbal and nonverbal communication
arrange phones call to family/friends
move to more stimulating environment as condition allows
Chaplain
assist in locating stores/pharmacies

 Medications:
n/a

Teaching:
effectively cope with isolation through use of exploring techniques (positive self-concept, self awareness)
church groups/outreach groups in area

 

Referrals:
Case manager for discharge planning, may need transportation home and help at home.
Chaplain - since new to area may not have spiritual needs meet, may want information on area churches.
Pulmonology consult - environment may trigger new respiratory symptoms.
Asthma and Allergy Foundation of America Website

AC EHR