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Posted: **Thu Apr 28, 2022 8:09 am**

: Typing Sounds Phone Rings Allyson Hello This Is Allyson Rn General Medical Unit At The Medical Center Cindy Th 1 (43.68 KiB) Viewed 26 times

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: Typing Sounds Phone Rings Allyson Hello This Is Allyson Rn General Medical Unit At The Medical Center Cindy Th 2 (43.68 KiB) Viewed 26 times

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: Typing Sounds Phone Rings Allyson Hello This Is Allyson Rn General Medical Unit At The Medical Center Cindy Th 8 (33.36 KiB) Viewed 26 times

(typing sounds) (phone rings) ALLYSON: Hello, this is Allyson, RN, General Medical Unit at the Medical Center. CINDY: This is Cindy in the Emergency Department. I'm sending you Mr. Gomez, a 68-year-old Latino gentleman. He came in with pneumonia and exacerbation of his COPD. His daughter found him on the floor at home, where he lives by himself. She said he was unresponsive. He recently lost his wife and there is a question of alcohol abuse. His temp is 99.2, pulse 100, respirations 36 and his sat is 91% on 5 liters of 02 per nasal cannula, His lung sounds are diminished in the bases. He has some occasional rhonchi, with wheezes in both the anterior and posterior upper lobes. His cough is productive of a greenish-yellow tenacious sputum. His blood pressure is 150 over 94. He denies pain. He appears anorexic although I don't know if he's had any recent weight loss. He's alert and oriented. I put a saline lock in his left wrist, which flushes fine. He voided 250 of clear, yellow urine. He's NPO. His antibiotic has not been given, but he's had two Albuterol nebulizer treatments. Check the MAR for his meds. We did ABG's, biood alcohol, CBC, chest x-ray, chem and metabolic profile, urine analysis and culture and sensitivity of his sputum. They're all nendinn This is the end of my report. We'll be up shortly. ALLYSON: Okay, thank you.
Laboratory Date: 08/01/XX Time: 0505 Complete Blood Count (CBC) Red Blood Count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Reticulocyte 4.8 million/mm3 9.3 g/dL 29% 0.78% of RBC White Blood Count (WBC) Platelet Count 13,000/mm3 162,000/mm3 Blood Chemistry Sodium Potassium Chloride Calcium Phosphorus Blood Urea Nitrogen (BUN) Creatinine 135 mEq/L 4.4 mEq/L 100 mEq/L 9.0 mg/dL 5.5 mEq/L 22 mg/dL 1.0 mg/dL. 1:20 ratio 3.0 mg/dL 17 mg/dL 180 mg/dL 40 units/L BUN/CT ratio Albumin Pre Albumnin Glucose ALT
Date: 08/01/XX Time: 0505 Arterial Blood Gases pH 7.30 PaO2 80 mm Hg PaCO2 54 mm Hg Bicarbonate 19 mEq/L SAO2 88 % 1 20 mg/dL Date: 08/01/XX Time: 0505 Blood Alcohol Concentration Date: 08/01/XX Time: 0505 Urinalysis Appearance Color Clear Yellow Odor Normal 1.002 Specific Gravity рн 5.8 Protein Leukocyte esterase Ketones Negative Negative Negative Negative Negative Negative Glucose WBC RBC
Order Date Stop Date 1900-0700 08/01/XX 2400 08/01/XX 08/01/XX Scheduled Medications 0700-1900 Ceftriaxone (Rocephin) 1 g IV bolus every 12 hr 1200 (administer over 30-60 min) Nicotine (Nicoderm) 21 ᎾᎾᎾᎾ CᎳ mg T daily Methylprednisolone 40 mg 0800 CW IV bolus Q 6hr Salmeterol (Serevent Diskus) 1 inhalation every 0809 DJ 12 hrs Albuterol (Proventil) 2.5 mg via nebulizer overy 4 0909 DJ hr (RT to administer) 0.9% sodium chloride 3 mL. IV bolus via saline lock 1200 1400 2000 0200 08/01/XX 2000 08/01/XX 1200 1600 2000 2400 0400 08/01/XX 2400 every 12 hr 08/01/XX PRN Medications Acetaminophen (Tylenol) 650 mg PO every 4 h PRN pain 0.9% sodium chloride 3 mL IV bolus via saline lock 0800 CW PRN 08/01/XX IV Therapy
Date/Time Orders Prog 08/01/XX 0600 Vital signs with oxygen saturation every 4 hours and PRN Oxygen via nasal cannula; titrate to keep oxygen saturation between 88% and 92% 08/01/XX 0600 08/01/XX 0600 NPO 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 Saline lock - flush per protocol Activity as tolerated Transfer to med-surg unit I & Check blood glucose every morning and at bedtime Ceftriaxone (Rocephin) 1 gram IV bolus every 12 hr Salmeterol (Serevent Diskus) 1 inhalation every 12 hr Albuterol (Proventil) 2.5 mg via nebulizer every 4 hr (RT to administer) Methylprednisone 40 mg IV bolus every 6 hr Nicotine (Nicoderm) 21 mg patch daily Acetaminophen (Tylenol) 650 mg PO every 4 hr PRN pain J. Wolburn MD (3738) (electronic signature) 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600 08/01/XX 0600
low Sheet Laboratory Report Medical Administration Record Orders and Progress Notes Radionty Report Radiology Report Patient: Gomez, Hector P. Sex: Male DOB: Age: 5. Ht: ati. 01/01//XX 08/01/XX Admit: MRN: 68 173 cm (68 inches) 71 kg (156 lb) Ampicillin 514926 Wt: ATI Clinical Reasoning Medical Center Physician: Peetze, Robert Allergies: Radiology Date: 08/01/XX Time: 0520 Notable hyperinflation of bilateral lung fields and flattened diaphragm. Changes characteristic of atelectasis in bilateral bases. Abnormal area of density present in the left lung base suspicious of pneumonia.
an University Department of Prelicensure Nursing Key Problem/ND #1 Key Problem/ND 2 Key Problem/ND #3 Medical Diagnosis Surgical Procedure: Key Problem/ND 14 Key Problem/ND #5 Key Problem/ND #6 Key Assessmes Key Problem/ND 27