Create a plan of care for a client diagnosed with bacterial pneumonia-must list at least two priority diagnoses (one of them physiological and one health promotion).

The care plan must include the following: For each diagnosis provide at least 3 interventions; at least three goals/plans; at least 3 evaluation criteria; at least three interventions for each.

Complete patient education must address the prevention of adverse treatment and health promotion; there should be a minimum of 4 teaching points. The patient education section should be completed in full.

 

Below is the patient information

 

Male, 01/31/1960 (62 years old), 173 cm, 63 kg

 

MRN: 26236

 

Attending: John Mack, MD

Allergies:

Demerol

Code Status: Full

Comments: none

 

• Patient Summary
• Patient Information
• Results
• Provider
• Allergies & Home Medications
• Immunization Record
• Notes
• Flowsheets
• Screenings
• MAR
• Orders
• Patient Education
• SBAR
• Care Plan
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Patient Summary

 

 

Primary Concern: Pneumonia

The Patient Summary is read only! To add or edit data you must open another page by clicking the appropriate tab to the left.

Vital Signs

	01/31/2022 2122
Heart Rate	106
Blood Pressure	90/60
Respirations	32
Temperature	36.89°C (Tympanic)
SpO2 (%)	90%
Pain	3

Allergies

Allergy	Date Noted	Reaction
Demerol		Hives

Orders

Type of order to view:

All DietImagingLabMedicationNursing/Other OrdersRespiratory

 

 

 

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Start Date	Order	Details	Status All ActivePast End
01/31/2022 1823	Activity-Bedrest with bathroom privileges Written order Frequency: Continuous Start Date: 01/31/2022 1823 End Date: 01/31/2022 1823		Past End
01/30/2022 2223	AMOXICILLIN Written order Dose/Frequency: 500 mg 2x Daily Route: Oral Start Date: 01/30/2022 2223 End Date:	Schedule: 0800, 2000	Active
01/31/2022 1823	Antiembolism stockings (TED) knee high Written order Frequency: Continuous Start Date: 01/31/2022 1823		Active
01/31/2022 1823	Arterial Blood Gases (ABG) Written order Frequency: Once Duration: 1 Start Date: 01/31/2022 1823		Active
01/30/2022 2223	ATORVASTATIN Written order Dose/Frequency: 20 mg Daily Route: Oral Start Date: 01/30/2022 2223 End Date:	Schedule: 2200	Active
01/31/2022 1823	Diet – Regular Written order Frequency: Continuous Start Date: 01/31/2022 1823		Active
01/31/2022 1823	Full code Written order Frequency: Continuous Start Date: 01/31/2022 1823		Active
01/31/2022 1823	Insert Intermittent Infusion Device (saline lock, med lock, hep lock) Written order Frequency: Continuous Start Date: 01/31/2022 1823		Active
01/30/2022 2223	MORPHINE SULFATE Written order Dose/Frequency: 4 mg Every 8 Hours Route: Intramuscular Start Date: 01/30/2022 2223 End Date:	Schedule: 0800, 1600, 0000	Active
01/31/2022 1423	Oxygen-nasal cannula 2L/min Written order Frequency: Continuous Start Date: 01/31/2022 1423		Active

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Labs

Lab	Range	01/31/2022 2032
Arterial Blood Gases (ABG)
pH	7.35 – 7.45	7.28
Carbon dioxide partial pressure (PCO2) (mm Hg)	35-45 mm Hg	56
Oxygen partial pressure (PO2) (mm Hg)	80-100 mm Hg	70
Bicarbonate (HCO3) (mEq/L)	22 to 26 mEq/L	25
Carbon Dioxide (CO2) (mEq/L)	23-28 mEq/L
O2 Saturation (%)	95% – 98%	89

 

 

 

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