Physiological and one health promotion

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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
  • Disch

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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

 

 

 

Search:

 

Show 102550100 entries

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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

Showing 1 to 10 of 14 entries

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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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