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
... [Show More] 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 Less]