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Posted: September 12th, 2022
Relate research from Canadian Nursing.
Patient diarrhea is decreasing and her vital signs T 37.6, R18,P76,BP 140/94 pulse oximetry 97% She complained of pain in her right legal pain level of 3 no edema, pedal pulse present. S
Subjective data: Married Her husband and son are supportive. Has an average of 5-10 loose stools per day. Anorexia, lactase deficiency, profound fatigue, frequent hospitalisations for dehydration.
Has recurring crippling abdominal pain, noticed pain in her Right leg.
Objective data:
Temp38 degrees Celsius, BP120/74 mmHg, Weight 140 lbs., height 5 feet, 10 inches , lab values Total bilirubin 257umol/L, Serum Ammonia 122umol/L, Serum Potassium 2.5mmol/L.
Age 46, hx of Crohn’s disease, dehydration/diarrhea, vs q4hr, I & O , Weight q am, bathroom privileges prn, right central line inserted, parenteral nutrition per IV pump @83 ml/hr, lipids 10% (M,W,D )infuse over 12 hours, BS Fingerstick q6hrs, Diet NPO, Vitamin k sc q1 weekly, Humulin regular 2 units if BG = 10-11 mmol/L , call Md if BG more than 11mmol/L.
Follow up Action plan:
Three hours later Mrs F family comes at the nurses station to say Mrs F is having diffculty breating . You go into Mrs F room and assess the following complaining of chest pain, R36, P134, BP108/88, Pulse oximetry 90% coughing , dyspnea, anxiousness, based on this what is your next step.
NOTE: DO NOT CUT AND PASTE /BE CLEAR CONCISE ACCURATE WITH WHAT YOU ARE ASKING THE PHYSICIAN
Remember you are not diagnosing your patient but providing information to the doctor to provide care
The doctor is not there so provide relevant information necessary to support your requests
Do NOT simply ask for the doctbcior to come and see the patient!
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