swift river new patients

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Hildegard Lowe Room 303 Hildegard Lowe, 68 y/o female, newly admitted after a rough night in the ER after coughing for the last 2 months. Patient is alert and cooperative, on Oxygen at 2L. She has ... an IV 0.9 normal saline, 125 an hour. Chest x-ray upon admission showed right middle lobe pneumonia. Vital signs are BP: 128/86, P: 105, R: 32, T: 99.8 F, 37.7 C, SaO2: 93%.. Plan of care is antibiotic therapy, incentive spirometry, O2 supplementation, and pending labs and blood cultures from the ER. Patient is receiving Rocephin and received Zithromax in the ER. Patient does have a history of Granulomatosis with Polyangiitis, but has been stable for 5 years w/o treatment. She is widowed, and came to us from the retirement community. She has one daughter who is on her way from out of state; she will be arriving sometime today. Patient states she is allergic to mangos. You responded correctly to 4 out of 6 evaluations: Category Your response ExplanEducational Needs Increased acuity Patient will need teaching on incentive spirometry, IV fluids, anFall risk Increased acuity Patient is receiving oxygen, and has an IV in place. Health change Increased acuity Patient has been sick for two months, and is now in the hospitaPain level Increased acuity Patient does not complain of pain at this time Psychological Needs Normal acuity No indication of increased need. Neurological Increased acuity No indication of abnormality Arthur Thomason Room 305 Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. You responded correctly to 4 out of 6 evaluations: Category Your response ExpEducational Needs Increased acuity Status assessment reports post op therapy (cough, turnHealth Change Increased acuity Status assessment reports recent major surgery and abLOC Increased acuity Status assessment reports slight confusion Pain Level Normal acuity Patient was in an MVA and has had surgery. Psychological Needs Normal acuity Patient is slightly confused and is anxious Safety Increased acuity Status assessment reports slight confusion Robert Sturgess Room 306 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Palliative care. No Known allergies (NKA). Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Neuro WNL alert and cooperative. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Blood Glucose 185, 4 units of insulin sliding scale for coverage. ADA diet, intake 25%. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Patient and family upset regarding dx. Dr. Donofrio You responded correctly to 6 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports Diagnosis- Colon CA, palliative care, intake 25%, pFall Risk Increased acuity Status assessment reports patient intake 25%, SIVP Demerol 25mg for pain, pHea [Show More]

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