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History of Present Illness
Two hours prior to admission, at 4am, patient Jake was jogging along Lacson
Street when a group of bystanders had approached him and stabbed him
multiple times. He claims that he does not know these people. He tried to
defend himself resulting to multiple injuries in his upper extremities where he
had 3 lacerations, cheeks where he had a laceration on the left, right chest and
right upper abdominal quadrant.
Medications:
Tetanus Toxoid 0.5 ml/amp, give 1 ampule via deep IM,
now at right deltoid
ATS 3,000 IU/amp, give 1 ampule via deep IM, now,
ANST at left deltoid
Piperacillin Tazobactam 2.25 grams/vial, give 1 vial via IV
drip to run for 3 hours Q8H
Tramadol 50 mg/amp, give 1 ampule very slow IV push
now then Q6 PRN for pain
Omeprazole 40 mg/amp, give 1 ampule via IVTT ODHS
Latest Vital Signs :
Blood Pressure: 90/60 mmHg
Heart Rate: 121 bpm
Respiratory Rate: 26cpm
Temperature: 37.3 ⁰C
Pain Scale: 10/10
NURSING CARE PLAN
Step by step
Solved in 2 steps with 1 images
- pathophysiology make table to differentiate ITP, TTP, HIT, DICHISTORY OF PRESENT ILLNESS: Edith Martens is a 66-year-old female who is recovering fromviral pneumonia. When her daughter came to check on her, she found Edith in bedcomplaining of weakness, constant fatigue and abdominal pain.For the past few days, Edith has been complaining of thirst and frequent urination. She alsoreports that she cannot see very well. Edith has lost approximately 4 lbs over the last week.Her daughter brought Edith to the ER. PAST HISTORY: There is a history of osteoarthritis that responds well to ASA. Edith wasdiagnosed with Type 2 diabetes approximately two years ago. She takes glyburide 10 mg everymorning before breakfast and is on an 1800 calorie diet, which she follows closely. SOCIAL HISTORY: Edith has lived alone since the death of her husband. She is not physicallyactive; her activities consist of light housework and occasional shopping trips. FAMILY HISTORY: Edith’s father had Type 2 diabetes complicated by peripheral vasculardisease. He died at the age of…HISTORY OF PRESENT ILLNESS: Edith Martens is a 66-year-old female who is recovering fromviral pneumonia. When her daughter came to check on her, she found Edith in bedcomplaining of weakness, constant fatigue and abdominal pain.For the past few days, Edith has been complaining of thirst and frequent urination. She alsoreports that she cannot see very well. Edith has lost approximately 4 lbs over the last week.Her daughter brought Edith to the ER. PAST HISTORY: There is a history of osteoarthritis that responds well to ASA. Edith wasdiagnosed with Type 2 diabetes approximately two years ago. She takes glyburide 10 mg everymorning before breakfast and is on an 1800 calorie diet, which she follows closely. SOCIAL HISTORY: Edith has lived alone since the death of her husband. She is not physicallyactive; her activities consist of light housework and occasional shopping trips. FAMILY HISTORY: Edith’s father had Type 2 diabetes complicated by peripheral vasculardisease. He died at the age of…
- PATHOPHYSIOLOGY :Infection After suffering with a cold for 5 days, Mr. Smith developed otitis media and sinus. The nasal secretions changed from thin, clear, and colorless to thick, yellow-green mucus. Fever and sore throat developed, as well as pain around the eyes and right ear. Initially, what type of infection do you think Mr. Smith initially had (bacterial or viral) and why? What changes in manifestations occurred during the course of his illness? What did these changes in manifestations mean or indicate with respect to the progression of his illness? Why does Mr. Smith have pain around the eyes and in the right ear? 5. What is the likely course of treatment for Mr. Smith?Mr. H is a 52-year-old male who presents to the emergency department. His left leg is in a cast, and he states that 1 week ago he was in an automobile crash and broke his upper leg. Since that time, he has had difficulty “getting around” and has mostly been lying on the couch watching television. On the evening of admission he noticed a sudden onset of dyspnea and chest pain. He denies having orthopnea, cough, hemoptysis, or wheezing. He smoked two packs of cigarettes a day for 19 years but quit 3 years ago. The ABG analysis of Mr. H suggests uncompensated respiratory alkalosis with mild hypoxemia, with base excess of -1 in her arterial side, whereas -4 in her venous side. Part 1: Her actual arterial-venous oxygen content difference (Ca-vO2) is 5.31 mL/dL. (Normal range considered here is 3.5 to 5 mL/dL) Part 2: Patient's actual oxygen extraction ratio (O2ER) was 29%. (Say normal range is 20-28%) What is clinically happening to the patient?Mr. Reddy is a 62 yo presenting to ED at 1500hrs. He was preparing the gas cylinder for a Sunday BBQ when it suddenly exploded while he was trying to connect the hose. Family standing by tried to extinguish the fire with their hands and tried to remove his clothing. Burns 30% TBSA – Face, hands, bilateral lower limbs. Complaints of severe pain and burning 10/10. Past Medical History: Hypertension, Type II DM Regular medications – Candesartan 8mg, Glimepiride 4mg, Metformin 500mg and Pravastatin 20mg. Fully vaccinated against COVID. Airway. - Patent, superficial burns to right side of face Breathing. - Spontaneous, RR-22mt, SPO2-92% RA, air-entry equal Circulation- Lower limb odema, cap refill 3 seconds, bilateral dorsal pedis pulses weak. BP- 88/50 mmHg, HR- 127/mt, sinus tachycardia, Disability - GCS-15 E4V5M6, PEARL- 3mm, Exposure - Temperature 35.9 deg Celsius. Full thickness burns to right lower limb and right arm, partial thickness burns to left lower limb, bilateral hands.…
- SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2). BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons. ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL:…SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2). BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons. ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL:…HISTORY OF PRESENT ILLNESS: Ms. Smith is a 43-year-old woman with past medical history that includes a pilonidal cyst. This was apparently removed when she was 18. Last July she presented with more pain in this area. On exam, it was apparently unclear if there was a recurrence. She was put on a course of Keflex and everything resolved. She presents to walk-in today saying that same thing has happened. She has had a couple days of increased swelling in this area. No fevers. Mild pain. Bowel movements are fine. PHYSICAL EXAMINATION: BP 122/74, pulse 82. She is afebrile. We had a female nurse chaperone in the room during the exam. In the upper aspect of her gluteal cleft there were several scars from her prior surgery. This area was mildly indurated. There was absolutely no erythema or fluctuance and it was not tender at all. No drainage. ASSESSMENT AND PLAN: Pilonidal cyst. We do not see any active evidence of an infection, but given her apparent response last July, we will give her…
- Pt who was at home treating her right foot infection with VNA support. VNA recommended she return to the hospital because she was not caring for herself. The pt has not been able to get up and walk around including going to the bath. She complains of discomfort with swallowing and so she is not consistently taking her medication. She denies chest pain and shortness of breath. She is dysphagia, stage 2 plantar heel ulcer and at her butt. Has bruises on both hands, both legs is discolor and peeling. High fall risk and wear diapers. Pain is 7 on a scale of 0-10 at her coccyx wound. Normal bowl sounds and lungs sounds and heart sound. Cellulitis of right lower extremities. Cardiac diet and hypertension. Base on this information please do the concept map in the imagePt who was at home treating her right foot infection with VNA support. VNA recommended she return to the hospital because she was not caring for herself. The pt has not been able to get up and walk around including going to the bath. She complains of discomfort with swallowing and so she is not consistently taking her medication. She denies chest pain and shortness of breath. She is dysphagia, stage 2 plantar heel ulcer and at her butt. Has bruises on both hands, both legs is discolor and peeling. High fall risk and wear diapers. Pain is 7 on a scale of 0-10 at her coccyx wound. Normal bowl sounds and lungs sounds and heart sound. Cellulitis of right lower extremities. Cardiac diet and hypertension. Vitals at 800: Vitals at 11:20Am: Pulse: 99 HR: 72 SPO2: 99. BP: 144/97 BP: 135/82. R: 17 Temp: 95:4 HR:70 R: 16 Base on the information above can you please do a intervention for each body system. Neurological, Musculoskeletal, cardiovascular, respiratory, integumentary, GI, GU Patient…18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs. Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions. On examination, 4cm laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries. Patient denies drug use, states has had approximately ‘five beers since 7pm’. Breath alcohol taken at 2330 hours 0.06%. Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation. Patient states is usually fit and well. Past medical history Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago).Not on any medications and no known allergies. Intervention: The decision is made to keep Zac in hospital overnight, for observation. Paracetamol is charted for pain. No other medications are…
