SCHOOL OF NURSINGTHIS IS A DADE
SCHOOL OF NURSING
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.
S
B
SITUATION
Admit Date: Wednesday 2000
Dx:
AIDS
Chief complaint: Patient Stated " I'm so weak, my legs are having burning pain, please don't touch"
BACKGROUND
Medical History:The patient contracted HIV 15 years ago, which progressed to AIDS 8 years ago.
Betadine
Allergies:
Code status: Do not resuscicate. (DNR).
Interventions/Responses:
A
Morphine, Lorezepam, Ibuprofen, Acetaminiphen, Pregabalin.
ASSESSMENT
Neuro: Patient alert and oriented. Pupils equal, round, reactive to light and accommodation.
Respiratory: Muffled bilaterally, dry cough.
S1 S2, Sinus tachycardia
Cardiac:
GI/GU: Hyperactive bowel sound, distended and slightly tender in middle, diarrhea, no voiding
Musculoskeletal: All extrimities weak, unable to ambulate.
Skin:
Pale, cool, and dry. Stage 3 pressure ulcer on right heel.
Psychosocial:
Anxious, jittery.
VITAL SIGNS
BP: 102/56
HR:
112
Pain:
85%
Resp:
12
Accu Check:
SpO2
R
N/A
RECOMMENDATIONS
Goals:
maximum comfort, die with dignity.
Consults:
Advanced medical surgical unit.
Test/Treatments:
Lab results:
Discharge needs:
NRF1073 R00
7/10
Analgesics. patient on paliative care.
None
None
Effective Date: 10/11/2013
Page 1 of 1
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.
S
B
SITUATION
Admit Date: Wednesday 2000
Dx:
AIDS
Chief complaint: Patient Stated " I'm so weak, my legs are having burning pain, please don't touch"
BACKGROUND
Medical History:The patient contracted HIV 15 years ago, which progressed to AIDS 8 years ago.
Betadine
Allergies:
Code status: Do not resuscicate. (DNR).
Interventions/Responses:
A
Morphine, Lorezepam, Ibuprofen, Acetaminiphen, Pregabalin.
ASSESSMENT
Neuro: Patient alert and oriented. Pupils equal, round, reactive to light and accommodation.
Respiratory: Muffled bilaterally, dry cough.
S1 S2, Sinus tachycardia
Cardiac:
GI/GU: Hyperactive bowel sound, distended and slightly tender in middle, diarrhea, no voiding
Musculoskeletal: All extrimities weak, unable to ambulate.
Skin:
Pale, cool, and dry. Stage 3 pressure ulcer on right heel.
Psychosocial:
Anxious, jittery.
VITAL SIGNS
BP: 102/56
HR:
112
Pain:
85%
Resp:
12
Accu Check:
SpO2
R
N/A
RECOMMENDATIONS
Goals:
maximum comfort, die with dignity.
Consults:
Advanced medical surgical unit.
Test/Treatments:
Lab results:
Discharge needs:
NRF1073 R00
7/10
Analgesics. patient on paliative care.
None
None
Effective Date: 10/11/2013
Page 1 of 1