11TH CASE SCENARIO.(Nursing)

Medical record # :Q000099956

Admitted: 03/01/2009.

Telemetry Floor: placed on monitor.

Robert Johnson Yetund.

Admitting Diagnosis:Upper GIB,Aspiration pneumonia, NSTEMI,Homeless.

PMH:Heroine abuse,Hep C, Asthma,EGD 05/2009(Large gastric Varies)On 05/05/2009 EGD done found large gastric esophageal, scheduled for colonoscopy on 05/06/2009. Patient remain noncompliance with plan of care.Left and came back two days later with swelling of bilateral lower extremities, fatigue and abdominal pain.

GCS = 15.

Height: 5ft 8inches

Weight: 166lbs.

Chest xray showed pulmonary edema.

Patient had nstemi.(Non S .T.sgment elevation.

Troponin 5.2

Patient had black/Tarry stools x3 days.

Hgb= 5.4.

Attending Doctor : Dr. Too Much.

Plan intervention:

Transfuse: 4units of PRBC.

Diuretic given

Nebulizer.

Protonix intravenously to help stop the bleeding.

Allergy: NKDA.

Diet :Regular diet.

Language: English speaking.

H/H after blood transfusions 8.2/25.8

PLAN:

Transfer to SNF when there is accepting SNF

No accepting SNF.

Declined by Rosemead FANS SNF.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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