Care Plan and Concept Mapping
Kenneth Bronson is a 27-year-old male who was just admitted to the Medical Unit from the Emergency Department. He presented to the Emergency Department two hours ago with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x-ray revealed right lower lobe pneumonia. IV was started of normal saline at 75 mL per hour. He is receiving oxygen at 2 L/min per nasal cannula. SpO2 on room air was 90%, which increased to 95% with supplemental oxygen. He had a temp of 102.6°F and was given acetaminophen 1,000 mg in the Emergency Department. Pharmacy just delivered the antibiotics to be given.
Jennifer Hoffman is a 33-year-old female brought to the Emergency Department by her neighbor. She has a history of asthma since childhood with multiple emergency visits within the last year. She appears to be in respiratory distress, struggling to breathe. She is unable to speak other than simple one-word statements. An infusion of normal saline has been started at a keep-open rate.
Vincent Brody is a 67-year-old male admitted directly from the provider’s office several hours ago for exacerbation of his chronic obstructive pulmonary disease (COPD). He is maintaining O2 saturations at 94% on 2 L/min of oxygen per nasal cannula. IV of potassium chloride in 5% dextrose and normal saline is infusing at 100 mL/hr in his right hand. He has responded well to medications and treatments and appears to be resting. He continues to have a productive cough. Patient has a 50-year history of smoking 2 packs a day. During the last year he has had two exacerbations. Physical findings include a barrel chest and clubbed fingers.
Carl Shapiro is a 54-year-old male who travels frequently. He was seen in the Emergency Department at 1:30 p.m. for complaints of chest pain, diaphoresis, and shortness of breath. He was treated in the Emergency Department with aspirin and two doses of sublingual nitroglycerin. Chest pain improved with nitroglycerin administration. IV infusion of normal saline was started in the Emergency Department and is running at 25 mL/hour. Ordered lab values are pending. Provider wants to be called as soon as the labs are available. Patient is receiving oxygen at 4 L/min with SpO2 values at 97%. Chest pain was last rated as a “0” following second nitroglycerin dose and nitroglycerine patch 0.4 mg. He has been admitted to the Telemetry Unit.
Skyler Hansen is an 18-year-old male diagnosed with type 1 diabetes 6 months ago. He was brought to the Emergency Department by his friends. The friends report that he started acting “weird” while they were playing basketball. He has not eaten anything for 5 hours. Skyler told them that he felt lightheaded and was going to lie down on the cement. They became nervous and decided to bring him in to the Emergency Department. The patient is drowsy, wakes with stimulus, has slurred speech, is diaphoretic, and is acting irrationally.
Stan Chekkets, 52-year-old patient has just arrived in the Emergency Department with complaints of severe abdominal pain, nausea, and vomiting over the last few days. His abdomen is distended. He has poor skin turgor and dry mucous membranes. He has not urinated since yesterday. He has felt “dizzy” and “weak” all evening. He thought it might be the flu, but decided to come in because the stomach pains were getting worse. He has signed informed consent for treatment and labs have been drawn.
Doris Bowman is a 39-year-old female patient who underwent a total abdominal hysterectomy with bilateral salpingo-oopherectomy with general anesthesia. Patient tolerated the procedure without complications. She has an abdominal incision covered with a 4 × 4 gauze dressing with no drainage noted. IV of potassium chloride in 5% dextrose and normal saline is infusing at 125 mL/hr. Estimated blood loss was 400 mL. She was extubated in the operating room and is breathing spontaneously at 21 breaths per minute. Blood pressure is stable at 154/92. She has a Foley catheter placed with 200 mL urine output and compression stockings have been applied.
Lloyd Bennett is a 76-year-old male who was admitted through the Emergency Department 2 days ago with a femoral head fracture sustained in a fall outdoors and underwent left hip arthroplasty. All drains have been removed. Provider changed the dressing this morning, and the dressing is currently clean, dry, and intact. Patient has complained of fatigue with physical therapy and does not tolerate changes in position without dizziness. Complete blood count this morning identified hemoglobin of 7 g/dL. The provider has ordered two units of packed red blood cells to be given. The lab has called and the first unit is ready.
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