Age: 84 Race: Caucasian Sex: Male MS: Divorced Chronic or Previous Health Problems (include date of onset if known):
-Arthritis
-COPD
-Lung dz
-Hypercholesterolemia
-HTN
-Cancer
-Multiple myeloma
-Muscle Cramps
-Thyroid
___________________________________________________
History of current symptoms: Denied any other pain or complications besides his arm Diet: Healthy Heart,
Height: 172.72 cm Weight: 86.18kg Code Status: Full Resuscitation Activity Ordered: Activity as tolerated
Religion: No preference Economic Status: Medicare Activity Possible: Bed rest. Activity as tolerated
Perception of Health/Reason for Admission (pt’s own words): Nutrition: ? PEG Tube PO
“I broke my arm”
Elimination: ? Foley ? Ostomy—Type: Void
I & O schedule:
Admitting Medical Diagnosis:
Syncope, Hypotension, ARI
Wounds/ Wound Care:
No wound care
Previous Surgeries (include date):
-Left heart cardiac 8/11/15
-Coronary arteriography using two caths 8/11/15
-Biopsy of bone marrow 4/16/15
-Eye
-Hernia
-HIp replacement,
-Knee
-Shoulder replacement
-Thyroid
Respiratory: No supplemental O2
? O2 @ ______ L/min via _________________________
? Incentive Spirometer every ___________
? Respiratory Treatments:
-Documented: Albuterol (Albuterol 90 mcg/inh inhalation) – 2 puffs, INH, BID, PRN SOB or wheezing
-Documented: Fluticasone-salmeterol – 1 puff, INH, BID # 60 EA
-Fluticasone-salmeterol (Advair Diskus 250 mcg-50 mg inhalation powder) – 1 puff, Inh-oral disk, INH, BID, Routine
? Ventilator Settings_________________________
Date of Admission: 2/12/17
Surgical Procedures: No surgeries since admission
Date:
Home Medications:
-Aspirin (Aspirin EC 81 mg) = 1 tab(s), oral daily
-Prochlorperazine (Compazine) = 1 tab, oral q 6hr
-Multivitamin with mineralys (PreserVision oral capsule) = 1 cap, oral, BID, presersivion with Lutein
-Fluticasone – Salmeterol – 1 puff, INH, BID, #60 EA
-Calcium-Vitamin D (Calcium 500 + D oral tablet, chewable) – 1 tab chewed BID
-Multivitamin – 1 tab, oral, daily
-Acetaminophen-hydrocodone (Norco 5mg/325mg) – 1 tab, oral, q4hr, PRN for pain
-Omega-3 polyunsaturated fatty acids (omega – 3 polyunsaturated fatty acids 1000 mg oral capsule) – 1,000 mg = 1 cap, oral, once a day (bedtime) #60 cap
-Potassium chloride – 10 mEq, oral daily
-Memantine (Namenda) – 10mg = 1 tab, oral, BID #60 tabs
-Cetirizine (Cetirizine 10 mg oral tab) = 10 mg = 1 tab, oral daily #30 tabs
-Cyanocobalamin (Vita B12 100 mcg oral tablet) – 100 mcg = 1 tab, oral, daily #30 tab
-Levothyroxine (levothyroxine 112 mcg (0.112 mcg) oral tablet) – 112 mcg = 1 tab, oral daily # tab
-Polyethylene glycol 3350 (MiraLax) – 17 gm 1 packet, oral, daily
PLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING TERM PAPERS TODAY AND GET AN AMAZING DISCOUNT
