IHUMAN PATIENT ASSESSMENT PLAN OF CARE. Latest 2021. Download for Grade A+

Document Content and Description Below

PLAN OF CARE IHUMAN PATIENT ASSESSMENT STUDENT: Date of Care: 3/27/2021 Age: 69 Gender: M Resuscitation Status Allergies none Reason for Admission: Heart Failure Exacerbation Medical ... Diagnoses: stage II right sided heart failure Surgeries/Procedures and Dates: Past medical history Coronary artery disease, Hyperlipidemia, Myocardial infarction, Hypertension, Stage 2 Right sided Heart failure Current Orders: Diet_low sodium (2 grams) diet; 2 liter fluid restriction _ Activity OOB with assistance Intake _N/A Output N/A Accu Cheks Vital signs. BP:126/72, Pulse:78/min, Tempt: 98.6F, Respiration:16/min, oxygen sat:98% on room air, Pain 0/10Drsg changes/wound care Foley N/A NG/G-tube/PEG?PEJ N/A IV right arm lower arm antecubital space Reason for IV normal saline 0.9%) 5MI IV Other orders: SCDs to bilateral lower extremities when not ambulating Titrate to keep O2 saturation above 92% weigh the patient every morning at the same time Most recent Imaging Findings: (CXR? CT? MRI?) Type of Imaging (X-Ray, CT, MRI, etc) Body Area Imaged Reason for testing and results of test x-ray AP Chest To view anatomy of lungs; Cardiomegaly and intestinal pulmonary edema Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Comments Lipid profile serum Cholesterol – 208 HDL- 45 LDL-115 Triglycerides- 129 Cholesterol – < 200 HDL- >45 LDL- < 100 Triglycerides- < 150 High levels of cholesterol, triglyceride, LDL; put at risk for heart dieases CBC All normal N/a Normal BMP All normal n/a Normal aPPT 30 secs 25-35 Normal [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages