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Posted: October 20th, 2022
Relate analysis from Canadian Nursing.
Affected person diarrhea is reducing and her very important indicators T 37.6, R18,P76,BP 140/94 pulse oximetry 97% She complained of ache in her proper authorized ache degree of three no edema, pedal pulse current. S
Subjective information: Married Her husband and son are supportive. Has a median of 5-10 free stools per day. Anorexia, lactase deficiency, profound fatigue, frequent hospitalisations for dehydration.
Has recurring crippling stomach ache, seen ache in her Proper leg.
Goal information:
Temp38 levels Celsius, BP120/74 mmHg, Weight 140 lbs., top 5 toes, 10 inches , lab values Whole bilirubin 257umol/L, Serum Ammonia 122umol/L, Serum Potassium 2.5mmol/L.
Age 46, hx of Crohn’s illness, dehydration/diarrhea, vs q4hr, I & O , Weight q am, toilet privileges prn, proper central line inserted, parenteral diet per IV pump @83 ml/hr, lipids 10% (M,W,D )infuse over 12 hours, BS Fingerstick q6hrs, Food plan NPO, Vitamin ok sc q1 weekly, Humulin common 2 items if BG = 10-11 mmol/L , name Md if BG greater than 11mmol/L.
Comply with up Motion plan:
Three hours later Mrs F household comes on the nurses station to say Mrs F is having diffculty breating . You go into Mrs F room and assess the next complaining of chest ache, R36, P134, BP108/88, Pulse oximetry 90% coughing , dyspnea, anxiousness, based mostly on this what’s the next step.
NOTE: DO NOT CUT AND PASTE /BE CLEAR CONCISE ACCURATE WITH WHAT YOU ARE ASKING THE PHYSICIAN
Keep in mind you aren’t diagnosing your affected person however offering info to the physician to offer care
The physician shouldn’t be there so present related info essential to Help your requests
Do NOT merely ask for the doctbcior to come back and see the affected person!
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