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Practicing - Age 78 admits to your unit from the ER at 9 am She states that she had been taking oral levofloxacin for pneumonia for 3

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Unformatted text preview: Age 78, admits to your unit from the ER at 9 am. She states that she had been taking oral levofloxacin for pneumonia for 3 days (prescribed by her regular provider) but her breathing feels like it has gotten worse and she is repeatedly coughing so she came to hospital. She complains that she has been a little dizzy on this new medication and that recent BMs have been “loose”. Med Hx: CAD, HTN, mod. congestive heart failure Current meds: Enalapril Atenolol Aspirin Furosemide She took all of her morning doses today. Assessment: auscultated rhonchi & wheezes, some work of breathing/accessory muscle use noted. Heart sounds S1S2. Peripheral pulses +2/4. Slight pallor, capillary refills 2 seconds to upper extremities, 3 seconds to lower extremities. Turgor 1 second tenting to sternum. A and O X 3. Weak but equal AROM. VS: T 99.8 P 87 R 21 BP 118/76 Sat 93% on room air Lab results: ABG: pH 7.37 CO2 36 HCO3 24 O2 89 WBC 14,000 Hemoglobin 15.7; hematocrit 51.5% BUN 25 mg/dl Serum creatinine 1.1 mg/dL Respiratory & blood culture results are pending. Orders: IV ceftriaxone 600 mg IV Q 12 hours IV azithromycin 500 mg IV daily O2 via NC to keep sat > 92%-no more than 4 L; notify if more than 4 L needed to maintain Encourage oral fluids, regular diet Continue home meds except for levofloxacin Bed rest Incentive spirometer Q2 hours Other information you want? CXR shows mod. Atelectiasis in bases Pt reports urination X 1 this am; has not gone since arrival at hospital; cup of coffee this am and 6 oz. water in the ER No edema Serum Na 138; K 3.6; Cl 100; Glucose 100; Ca 9.1 UA WNL except small protein 3 meals yesterday; piece of toast this am Sputum is yellow, thick...
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This note was uploaded on 02/15/2011 for the course NURS 314 taught by Professor Chappell during the Fall '10 term at South Carolina.

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Practicing - Age 78 admits to your unit from the ER at 9 am She states that she had been taking oral levofloxacin for pneumonia for 3

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