Ms. Shirley Grace a 68 year old
Ms. Shirley Grace a 68 year old Female, single and lives alone, and presents with chief complaints of pain to left hip, radiating to left leg rating pain level “11” on the numeric scale 0 – 10. Client is currently admitted with a medical diagnosis of Left Hip Fx. On this admission, client reports medical h/o HTN, CAD, Obesity, DM, Chronic pain > 3 months to left Hip, Hyperlipidemia (HLD), smoke one pack cigarette a day, client denies elicit drugs and alcohol. Client Denies Claudication and paresthesia symptoms at the affected site. Current medications: Oxygen 2 liter via N/C, continuous Metoprolol Tartrate 25 mg 1 tab oral two time Heparin injectable 5,000 unit subcutaneous every 12 hours Insulin Garglene injectable (Lantus) 20 unit Subcutaneous at bedtime Pantoprazole 40 milligrams 1 tablet oral every day Simvastatin 10 my 1 tab oral daily at bedtime Meds PRN Acetaminophen 325 mg 2 tabs oral every 6 hours as PRN (needed )(1 – 3) Hydromorphone injectable 1 mg IVP every 6 hours PRN (as needed) (7 – 10) Oxycodone 5 mg/Acetaminophen 325 mg 2 tabs oral every 4 hours PRN (as needed) 4 – 6. Physical assessment findings: Ms. SG appears anxious, moderately dyspneic at rest. Color WNL for ethnicity Vital signs (V/S) B/P 130/80, HR. 110, R. 22. oxygen oxymetry: 92% in 2 L via N/C ABG: PC02 45, PAO2 92%, PH 7.38 Weight: 170 Lbs, height: 5.4 Labs: On admission Peak Flow Rate (PFR) 60% which indicates mild dyspnea. Lungs clear on auscultation CBC: Hemoglobin 14 and Hematocrit 45 (H/H) 16/49, WBC: 5,000. Review of system information (ROS): Neurological: Alert and oriented to time, place, and person. Good historian Respiratory: Mild Dyspnea Breath sounds: inspiratoty = expiratory, and on auscultation Adventitious sounds: None findings bilaterally Cardiovascular: Heart rate 110 strong and regular Jugular venous distention: Negative on assessment Peripheral edema 2 + Elimination Pattern Gastro intestinal (GI): Abdominal soft. nondistended Bowel sounds present in all four quadrants Bowel habits: Consistent. Last BM: 9/16/2022: Stools characteristics: Firm Genitourinary (GU): As per patient states, no abnormality upon urination. Void frequently, color: Clear yellow urine Mobility: Mobile with unsteady gait Integumentary (skin): Dry, warm, and intact Skin color: WNL for etvhnicity Diet: 2 grams sodium as ordered Oral fluids: No restrictions Image transcription text DISORDER/DISEASE PROCESS REVIEW MODULE CHAPTER Alterations in Pathophysiology Related Health Promotion and Health (Diagnosis) to Client Problem Disease Prevention ASSESSMENT SAFETY CONSIDERATIONS Risk Fa… Show more
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