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GIVE 5 NCP

GIVE 5 NCP

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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GIVE 5 NCP

9:55 AM Sat Mar 12 @ 40% A cdn.fbsbx.com DATE: ORDER 1/29/2022 >Please admit to room under the service of Dr. G. 11 АМ >Secure consent for admission & management T 36.8 P 94 R 20cpm >TPR q shift include BP >Diet for AGE PROBLEM: ROI (L) FEMUR ВР >Diagnostics: 100/60 02 sat 99 >CBC, Plt Count >Blood Typing > СТВТ > Urinalysis >CXR APL View; Xray Left Thigh, APL View > HbS antigen determination >Attach RT-PCR result done as OPD >For Removal of Implant (L) Femur, tomorrow 1/30/2022 at 1PM Wt 38.5 >Secure informed consent Ht 143.5 >Inform OR > Refer to Dr. A for anesthesia care. >Refer to Dr. PC for Pedia Clearance. >Secure 1 unit of FWB of patient's blood type properly screened and crossmatched, for possible OR use >Patient database % Surgery Intern-on-duty >Monitor 1&O q shift >Refer for untoward manifestations >Refer accordingly Dr. G MEDICATIONS: 3/30/2021 >Clindamycin 600mg IVTT q 8hrs ANST >Famotidine 10mg IVTT q 12hrs to complete 4 doses >Paracetamol 600mg IVTT q 6hrs x8 doses >Ketorolac 30 mg IVTT q 6hrs x8 doses >Metoclopramide 6mg IVTT q 6hrs PRN for persistent nausea/vomiting TPR Sheet: 3/29 3/29 3/29 3/30 3/3 3/30 3/30 3/30 3/31 4PM 8PM | 12M 12N 8PM | 12M 4A N 4AM 8A N N M M Res 24/ 24/ 24/ 24/ 22/ 24/ 24/ 24/ 24/ 36.5 36.1 p/ Tem 36.2 36.0 36. 36.0 36.4 | 36.6 36.4 ВР 90/6 90/6 90/60 90/6 | 100 | 100/ 100/ 100/ 100/ 170 70 60 70 60
Transcribed Image Text:9:55 AM Sat Mar 12 @ 40% A cdn.fbsbx.com DATE: ORDER 1/29/2022 >Please admit to room under the service of Dr. G. 11 АМ >Secure consent for admission & management T 36.8 P 94 R 20cpm >TPR q shift include BP >Diet for AGE PROBLEM: ROI (L) FEMUR ВР >Diagnostics: 100/60 02 sat 99 >CBC, Plt Count >Blood Typing > СТВТ > Urinalysis >CXR APL View; Xray Left Thigh, APL View > HbS antigen determination >Attach RT-PCR result done as OPD >For Removal of Implant (L) Femur, tomorrow 1/30/2022 at 1PM Wt 38.5 >Secure informed consent Ht 143.5 >Inform OR > Refer to Dr. A for anesthesia care. >Refer to Dr. PC for Pedia Clearance. >Secure 1 unit of FWB of patient's blood type properly screened and crossmatched, for possible OR use >Patient database % Surgery Intern-on-duty >Monitor 1&O q shift >Refer for untoward manifestations >Refer accordingly Dr. G MEDICATIONS: 3/30/2021 >Clindamycin 600mg IVTT q 8hrs ANST >Famotidine 10mg IVTT q 12hrs to complete 4 doses >Paracetamol 600mg IVTT q 6hrs x8 doses >Ketorolac 30 mg IVTT q 6hrs x8 doses >Metoclopramide 6mg IVTT q 6hrs PRN for persistent nausea/vomiting TPR Sheet: 3/29 3/29 3/29 3/30 3/3 3/30 3/30 3/30 3/31 4PM 8PM | 12M 12N 8PM | 12M 4A N 4AM 8A N N M M Res 24/ 24/ 24/ 24/ 22/ 24/ 24/ 24/ 24/ 36.5 36.1 p/ Tem 36.2 36.0 36. 36.0 36.4 | 36.6 36.4 ВР 90/6 90/6 90/60 90/6 | 100 | 100/ 100/ 100/ 100/ 170 70 60 70 60
9:55 AM Sat Mar 12 * * © 40% A cdn.fbsbx.com CHIEF COMPLAINT: For Removal of Implant (L) Femur 1/30/22; Fracture Left Femur S/P ORIF (7/7/2021) HEIGHT: 143.5 cm WEIGHT: 38.5 kg BMI 18.7 HISTORY OF PRESENT ILLNESS PHYSICAL EXAM 1/29/2022 (+) good sleep (-) cough, colds (+) good appetite (+) awake, comfortable, active (-) nasal flaring (-) retractions (+) clear breath sounds (-) wheeze, ap, NRRR, murmur (+) soft abdomen Full and equal pulses (+) left femur post-surgical scars No limitation of movement PAST MEDICAL HISTORY DIAGNOSIS NOI: MVA TOI: 6PM DOI: June 30, 2021 POI: Pob. McArthur Leyte ADX: Fracture Left Femur S/P ORIF (7/7/2021) PMI: Fracture Left Femur S/P ORIF (7/7/2021), SARS COV 2 Negative, Normal Nutritional Status History ALLERGIES Lab Results: No known allergies. CBC: WBC 6.9 HGB 138 HCT 0.42 PLT CT 350 NEUTRO 62 FAMILY HISTORY LYMPH 30 Father - construction worker/farmer EOS Mother - died when the patient was 3 y/o due to ovarian cancer. No other siblings. 4 BASO BLD TYPE A+ CT 3 MIN 3 SEC
Transcribed Image Text:9:55 AM Sat Mar 12 * * © 40% A cdn.fbsbx.com CHIEF COMPLAINT: For Removal of Implant (L) Femur 1/30/22; Fracture Left Femur S/P ORIF (7/7/2021) HEIGHT: 143.5 cm WEIGHT: 38.5 kg BMI 18.7 HISTORY OF PRESENT ILLNESS PHYSICAL EXAM 1/29/2022 (+) good sleep (-) cough, colds (+) good appetite (+) awake, comfortable, active (-) nasal flaring (-) retractions (+) clear breath sounds (-) wheeze, ap, NRRR, murmur (+) soft abdomen Full and equal pulses (+) left femur post-surgical scars No limitation of movement PAST MEDICAL HISTORY DIAGNOSIS NOI: MVA TOI: 6PM DOI: June 30, 2021 POI: Pob. McArthur Leyte ADX: Fracture Left Femur S/P ORIF (7/7/2021) PMI: Fracture Left Femur S/P ORIF (7/7/2021), SARS COV 2 Negative, Normal Nutritional Status History ALLERGIES Lab Results: No known allergies. CBC: WBC 6.9 HGB 138 HCT 0.42 PLT CT 350 NEUTRO 62 FAMILY HISTORY LYMPH 30 Father - construction worker/farmer EOS Mother - died when the patient was 3 y/o due to ovarian cancer. No other siblings. 4 BASO BLD TYPE A+ CT 3 MIN 3 SEC
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