Emphysema Case Study

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0700 61 year old female admitted with pneumonia with the history of Emphysema for 12 year. Alert and oriented x 4. Vital sign, T 102 F, P112, R 32, and BP 168/94. Patient denies chest pain or any discomfort at this time no s/s or c/o distress heart sounds normal S1 and S2. Oxygen @2L per Nasal cannula in place SpO2 90%. IV infusion running at 75ml/hr via infusion pump. Dressing to the IV site dry and intact no redness or swollen noted. Respiration noted to be shallow and labored. Lungs sounds bilateral coarse crackles auscultated throughout lung field. Heart rate and rhythm regular and even. Sinus tachycardia noted. Positive Bowel sounds on all 4 quadrants. ABD soft no tender to touch no masses noted. Currently in bed resting Call light and…show more content…
Results pending, Temperature 101.1 F, 02SAT 92% no s/s or c/o of distress or discomfort at this time will continue to monitor… ……………………………………………………………………………………………………………….…..L.Gotora PNS1/WATC 1000 Pt in bed resting no s/s or c/o of distress or discomfort at this time, HOB at 30 degree angle ,oxygen @ 2L per nasal cannula in place call light within reach will continue to monitor…………………………………………………………………………………………………….L.Gotora PNS1/WATC 1115 Vital sign taken T 100.9 F, P 94, R 30, BP 170/96. SpO2 89% oxygen @ 2 L per nasal cannula. Patient c/o of SOB no s/s of distress denies chest pain normal heart sounds S1 and S2 Head of the bed raised to 45 degree angle. Oxygen increased to 3 L per nasal cannula oxygen saturation up to 93%. Acetaminophen 650mg as directed per physician order ………………………………………………………………….................................................L.Gotora PNS1/WATC 1200 Pt in bed resting no s/s of distress or discomfort denies any SOB or chest pain respiration even none labored. Temperature 99.9, 02SAT 94% oxygen in place and continue as directed. Patient continue to have poor appetite on this shift ate 25% for breakfast and 30% for lunch snacks provided patient ate 60% of her snacks .Staff will continue to provide snacks between meals fluids encouraged ………………………………………………………………………….…………L.Gotora

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