Client Room 59, she is 79-year-old admitted for high blood pressure, dizziness headache. Primary diagnosed with brain mass.
\n\u2013 Code states: limited resuscitation
\n\u2013 Allergies: codeine
\n\u2013 History of COPD, tobacco use, and type 2 diabetes mellitus
\n\u2013 Vital signs were stable, but blood pressure was 179\/97 in the morning and improved to 138\/72 in the afternoon by BP meds.
\n\u2013 Neuro\/psychosocial: Alert, awake
\n\u2013 Activity\/Rest: feels Weakness, uses a walker.
\n\u2013 Cardiovascular: WNL
\n\u2013 Respiratory: Resp is 16 and O2 is 98. Shortness of breath due to asthma
\n\u2013 Nutrition & fluid balance: Regular appetite, no difficulty eating
\n\u2013 Skin: Dry and warm, no wounds, no drains.
\n\u2013 GI: Bowel sounds normal, active, and present. Last bowel movement was on 5\/23\/23
\n\u2013 GU: No abnormalities
\n\u2013 Emotional support provided by staff and family
\nLab values
\nglucose 300 normal limt 70-99
\nWBC 13.1. Normal limt 3.0 \u2013 12.9
\nRBC 5.12 NL 3.60-5.15
\nHematocrit 45.4. NL. 34.0 \u2013 45%
\nPlatelet count 371 NL 130-370
\n-Meds
\nCarvedilol tablet 50mg
\nDexamthosone injection 6mg
\nioratdine (claritin) 40 mg
\npolyethylene glycol (miralax) 17 gram
\numectidium 62.2 mcg inhaler
\ninsulin glargine 18 unit
\n_____________________
\nPatient Summary<\/p>\n
Name: Client Room 59
\nAge: 79
\nSex: Female
\nDiagnosis: Brain mass
\nAllergies: Codeine
\nHistory: COPD, tobacco use, type 2 diabetes mellitus
\nVital signs:
\nBP: 179\/97 in the morning, 138\/72 in the afternoon
\nHR: 80
\nRR: 16
\nTemp: 98.6\u00b0F
\nSpO2: 98%
\nNeuro\/psychosocial: Alert, awake
\nActivity\/Rest: Feels weakness, uses a walker
\nCardiovascular: WNL
\nRespiratory: Resp is 16 and O2 is 98. Shortness of breath due to asthma
\nNutrition & fluid balance: Regular appetite, no difficulty eating
\nSkin: Dry and warm, no wounds, no drains.
\nGI: Bowel sounds normal, active, and present. Last bowel movement was on 5\/23\/23
\nGU: No abnormalities
\nEmotional support provided by staff and family
\nLab values:
\nGlucose: 300 (normal limit: 70-99)
\nWBC: 13.1 (normal limit: 3.0 \u2013 12.9)
\nRBC: 5.12 (normal limit: 3.60-5.15)
\nHematocrit: 45.4 (normal limit: 34.0 \u2013 45%)
\nPlatelet count: 371 (normal limit: 130-370)
\nMedications:
\nCarvedilol tablet 50mg
\nDexamethasone injection 6mg
\nIoratdine (claritin) 40 mg
\nPolyethylene glycol (miralax) 17 gram
\nUmectiduim 62.2 mcg inhaler
\nInsulin glargine 18 unit
\nNursing Diagnosis<\/p>\n
Risk for falls: The patient is at risk for falls due to weakness, use of a walker, and shortness of breath.
\nImpaired physical mobility: The patient is experiencing impaired physical mobility due to weakness and shortness of breath.
\nIneffective airway clearance: The patient is experiencing ineffective airway clearance due to shortness of breath.
\nRisk for infection: The patient is at risk for infection due to high blood sugar and COPD.
\nNoncompliance with medication regimen: The patient is noncompliant with medication regimen due to cost and forgetfulness.
\nNursing Interventions<\/p>\n
Risk for falls: Implement fall precautions, such as using a bed alarm and side rails. Assist the patient with ambulation and provide assistive devices as needed.
\nImpaired physical mobility: Encourage the patient to participate in activities of daily living as tolerated. Provide assistive devices as needed. Assist the patient with ambulation and provide assistive devices as needed.
\nIneffective airway clearance: Administer bronchodilators and expectorants as ordered. Encourage the patient to cough and deep breathe. Suction the patient as needed.
\nRisk for infection: Monitor the patient’s temperature, WBC count, and sputum culture results. Administer antibiotics as ordered.
\nNoncompliance with medication regimen: Educate the patient about the importance of taking medications as prescribed. Assist the patient in accessing financial resources to help pay for medications. Develop a medication schedule that is easy for the patient to follow.<\/p>\n","protected":false},"excerpt":{"rendered":"
Client Room 59, she is 79-year-old admitted for high blood pressure, dizziness headache. Primary diagnosed with brain mass. \u2013 Code states: limited resuscitation \u2013 Allergies:\u2026<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[37,35,41,34,38,40,42,39,33,32,36],"tags":[47,43,44,51,49,45,48,50,46],"class_list":["post-481","post","type-post","status-publish","format-standard","hentry","category-apa-citation-format-assignment","category-assignment-writers-australia-college-student","category-buy-essay-usa","category-cheap-essay-writing-service-us","category-help-write-a-page-assignment","category-i-need-someone-to-do-my-assignment-within-hours","category-need-assistance-completing-the-assignment","category-need-to-write-an-essay","category-thesis-writing-service-sample","category-write-my-dissertation-usa","category-write-pages","tag-assignment-writers-canada-university-cost","tag-best-dissertation-writers-china","tag-doctoral-dissertation-writing-service","tag-free-ai-english-assignment-writers-china","tag-in-page-paper-write-an-essay","tag-need-help-completing-this-assignment","tag-professional-assignment-writers-usa","tag-uae-1-cheap-assignment-writing-service","tag-write-a-word-essay"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts\/481","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/comments?post=481"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts\/481\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/media?parent=481"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/categories?post=481"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/tags?post=481"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}