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CASE PRE. GROUP 4.docx - PATIENT’S KARDEX Name of Patient:...

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PATIENT’S KARDEXName of Patient: Patient HBAge:38 years oldGender: MaleRoom Number:#03Chief Complain:Right Sided Chest Pain, DyspneaPhysician: Dr. CharlesGuzmanAdmitting diagnosis: BronchopneumoniaCurrent Assessment:8: 30AMVital SignsTemp: 38. 6cBP: 90/60PR: 97 bpmRR: 32 cpmPhysical Assessment•Patient is awake, conscious andcoherent but looks weak andanxious.•With 02 support via face mask at2LPM•Lips look pale in color. Patientverbalized itchiness on throat anddifficulty on clearing his throat. Teethare clean with whitish color.•Upon auscultation, breathe soundthat sounds like scratching astainless steel is heard. It is near onthe sound of the breath sound“crackles”. Percussion was not done.Use of accessory muscles whilecoughing was noted. The patientverbalized that he feels difficulty onbreathing.•Pale conjunctiva was noted uponinspection of the eyes.•Skin appears pale, capillary refilltime is greater than 2 seconds.Special Orders:•Pls. admit to ROC under myservice•Secure consent for admission•Monitor VS q 2o & record•Give O2 support at 2 LPM viaface mask•Relay lab results to AP onceavailable•Refer accordinglyIVF:D5LRS 1L x 10oD5NM 1L x 10oDiet:DAT with SAPMedications:Laboratories/ Diagnostics:CBC, Urinalysis, Na, KCXR-PA, RBS, BUN,Crea, ABGParacetamol 500mg/tab 1tabq4o PRN for T o =37.8Sinecod Forte 1 tab TIDVentolin 1 neb now then q8hoursLevofloxacin 500mg/tab,1tab ODCeftriaxone 1g q12hoursANST
NURSES NOTESPATIENT’S NAMEAGEGENDERC/SRM/BED#HOSPITAL#Mr. HB38MS30441208**PLEASE AFFIX SIGNATURE OVER PRINTED NAME AT THE END OF THE ENTRYDATE/SHIFT/ TIMEFOCUSNOTES (DATA, ACTIONS, RESPONSE)
04/13/20218:30 AM9:00 AM10:00 AM10:30 AM11:00 AM11:30 AM1:00 PM1:30 PM2:00 PM3:00 PMIneffective airwayclearanceHyperthermiaActivity intoleranceReceived patient lying on his bed awake,conscious and coherent but looks weak andanxious with ongoing O2 support via face mask at2LPM.with V/S of Temp-38.6c, BP-90/60, PR-97 bpm,RR-32 cpmlips look pale in color and Pale conjunctiva wasnoted upon inspection of the eyes.capillary refill time is greater than 2 secondswith crackles and dyspneaEstablish rapportAuscultated breath soundAssessed cough effectiveness and productivityMonitored vital signs and recordedAssessed the patient’s hydration statusPosition on high back restInstructed deep breathing exercises, coughing andsplinting in upright positionEncouraged increase fluid intakeSuctioned the patient as indicatedEncouraged patient to restAdministered Ventolin as prescribedPatient have negative signs of difficulty ofbreathingPerformed TSBAdvised to wear loose and comfortable clothesEncouraged patient to increase fluid intake

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Term
Fall
Professor
NoProfessor
Tags
cough, bronchopneumonia

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