Make a nursing care plan Assessment Nursing Diagnosis Planning Implementation Evaluation Mrs.Nena dela Cruz 62 year old woman presents to the ER with complaints of shortness of breath, fatigue, and nausea. The patient reports that she developed a cold last week and does not seem to be improving. She has a productive cough and reports yellow/tan mucus. When asked about a fever, the patient said she does not own a thermometer but says that she feels “very hot one minute and very cold the next minute.” Upon assessment, the patient appears diaphoretic. Her temperature is 38.5 C, heart rate is 114 BPM, blood pressure is 105/75 mmHg, respiratory rate is 28 breaths per minute, and oxygen saturation is 90% on room air. The patient has a weak cough and is observed taking fast, shallow breaths. Crackles are auscultated throughout her lungs. The patient’s labs are normal but white blood cells are elevated at 20,000 per microliter . A chest x-ray is ordered and reveals bilateral lobar consolidations. Suspecting pneumonia, a sputum sample is sent to the lab for analysis and the culture later reveals streptococcus pneumoniae. The patient is admitted to the hospital for Pneumonia. Medications Given while in the ward Cefuroxine 500mg q6 IVT ANST Solmux 500mg 1tab TID Vit C 500mg 1 tan OD

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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Make a nursing care plan Assessment Nursing Diagnosis Planning Implementation Evaluation Mrs.Nena dela Cruz 62 year old woman presents to the ER with complaints of shortness of breath, fatigue, and nausea. The patient reports that she developed a cold last week and does not seem to be improving. She has a productive cough and reports yellow/tan mucus. When asked about a fever, the patient said she does not own a thermometer but says that she feels “very hot one minute and very cold the next minute.” Upon assessment, the patient appears diaphoretic. Her temperature is 38.5 C, heart rate is 114 BPM, blood pressure is 105/75 mmHg, respiratory rate is 28 breaths per minute, and oxygen saturation is 90% on room air. The patient has a weak cough and is observed taking fast, shallow breaths. Crackles are auscultated throughout her lungs. The patient’s labs are normal but white blood cells are elevated at 20,000 per microliter . A chest x-ray is ordered and reveals bilateral lobar consolidations. Suspecting pneumonia, a sputum sample is sent to the lab for analysis and the culture later reveals streptococcus pneumoniae. The patient is admitted to the hospital for Pneumonia. Medications Given while in the ward Cefuroxine 500mg q6 IVT ANST Solmux 500mg 1tab TID Vit C 500mg 1 tan OD

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