The prevention of adverse treatment and health promotion
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:
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| Start Date | Order | Details | Status All ActivePast End |
|---|---|---|---|
| 01/31/2022 1823 | Activity-Bedrest with bathroom privileges Written order Start Date: 01/31/2022 1823 | Past End | |
| 01/30/2022 2223 | AMOXICILLIN Written order Start Date: 01/30/2022 2223 | Schedule: 0800, 2000 | Active |
| 01/31/2022 1823 | Antiembolism stockings (TED) knee high Written order Start Date: 01/31/2022 1823 | Active | |
| 01/31/2022 1823 | Arterial Blood Gases (ABG) Written order Start Date: 01/31/2022 1823 | Active | |
| 01/30/2022 2223 | ATORVASTATIN Written order Start Date: 01/30/2022 2223 | Schedule: 2200 | Active |
| 01/31/2022 1823 | Diet – Regular Written order Start Date: 01/31/2022 1823 | Active | |
| 01/31/2022 1823 | Full code Written order Start Date: 01/31/2022 1823 | Active | |
| 01/31/2022 1823 | Insert Intermittent Infusion Device (saline lock, med lock, hep lock) Written order Start Date: 01/31/2022 1823 | Active | |
| 01/30/2022 2223 | MORPHINE SULFATE Written order Start Date: 01/30/2022 2223 | Schedule: 0800, 1600, 0000 | Active |
| 01/31/2022 1423 | Oxygen-nasal cannula 2L/min Written order 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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