NURS 410 Bowie State University Acute Care Patient Paper and PPT
NURS 410 Bowie State University Acute Care Patient Paper and PPT
78 YO African-American Female Religion: Baptist Full Code
ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Presented via ambulance from a nursing home where he is a long term resident. He had altered mental status. 2 days ago he had a fall
He has past medical history of Dementia, Diabetes Type 2, Depression, HTN, CAD,
Home Meds: Enelapril, Lopressor, Cardizem, glipizide, Senna, Lovastatin. Gabapentin, Calcitrate with D, tylenol
Physical Exam: Neuro: Alert, confused, clear speech. Able to follow command CVS: heart s1 s2 no murmur, HR 110 regular BP 120/69 cap refill > 2 seconds, no peripheral Edema. Saline lock line left forearm Resp: lungs diminished throughout. Cough productive, unlabored resp, RR 24. Pulse oximeter 93% on oxygen 2l/min by nasal cannula GI: Bowel sounds-normoactive , Abd soft, non-tender. Poor oral intake, bowel incontinent GU: urinary incontinence Muscskel: non-ambulatory, requires one assist to chair Skin: No bruises, rashes. No skin breakdown
Admitting diagnosis: Pneumonia, Acute Kidney Injury, encephalopathy, symptomatic,
Hospital Medications: Heparin 5000 U Q12h SQ, Zosyn , Kay Exalate,
Diagnostic Test: Chest Xray: bilateral pneumonia Head CT- no acute changes, atrophy consistent with aging, NURS 410 Bowie State University Acute Care Patient Paper and PPT Chest CT- Hilar mass with lymphadenopathy EKG- no changes BMP: Glucose 180, Na 141, Cl 110, K 6.2, BUN 30, Creat 2.7, Ca 16.9 CBC: WBC 26.1 Hgb 11.2, Hct 33.3, Plt 150, HCO3 23 |
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