Productive cough has Pneumonia

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Reference no: EM133845403

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Patient details

A 74-year-old male with productive cough has Pneumonia. NKA. The patient is on ensure 2g sodium diet. Activities as tolerated and on full code status.

Patient had medical history of AAA, hyperlipidemia, hypertension, pneumonia and thrombosis.

Patient is alert, awake and oriented x 4. Daily weight of 140 lb. Intake is 100% and 150 ml urine output from last 3 hrs, continent urine status, Patients respiration is regular and symmetrical chest expansion. O2 via nasal cannula. Irregular cardiac rate and heart sound S1, S2 .Skin is dry and intact. Patient have risk for aspiration, fall, safety and skincare. Patients psychosocial is within defined limits. Patient have AROM in BUE and LROM in BLE. Patient reports normal bowel movement. Peripheral IV in left hand, left forearm. Iv lines are clean, dry, intact. Current vital are: T is 98.8, P is 103, RR 20 normal, BP is 18/78, O2 saturation is 93% RA. Abnormal lab values are Bun 44, Calcium 8.3, RBC 3.96, APTT 128.5, eGFR 58, Sodium 133, Glucose 159

MEDS- DEXTROMETHORPHAN

Dose/Frequency: Every 6 Hours

PIPERACILLIN/TAZOBACTAM IN 0.9% NACL

Albuterol

acetaminophin

budesinode

ondansentron

Reference no: EM133845403

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