LONDON SCHOOL OF PROFESSIONAL HEALTH SCIENCES, LOS ANGELES,CALIFORNIA 900000.
Student Nurse name:Lovesoda,Icecre.
SITUATION: Room 3124.
Chief complaint: SOB,Chest pain.
Primary Diagnosis: Atria Fibrillation. Surgery/ Procedures:Echocardiogram. BACKGROUND:
CODE STATUS: FULL CODE.
Intervention: 02@2liter NC.
Blood pressure medication given as ordered by the doctor. Assessment of pain,medicate as ordered with morphinesulfate 4mg IVQ3hours prn pain.Reasssessment in 30minutes.
Monitor blood pressure and notify the doctor for any critical value.
Neuro: Headache, dizziness.
Cardiac: Chest pain.
GI/GU: Dialysis, Nocturia.
Musculoskeletal : Weakness LLE,Swelling.
Skin: Intact. No skin breakdown.
Psychological: Anxiety, depression.
Vital sign/pain: BP:,140/88,Hr:108,Temperature: 98.0,Resp:20.
Height:5ft 4inches. Ambulates to the bathroom. No bowel movement today.
Blood sugar: N/A.
Xray: Chest Xray results: Pending.
IV lines/Fluids: Saline lock right ac 20guage,patent/clean/dry. RECCOMENDATION:
Vital signs within normal range.
Consultation: Cardiology consult.
Educate patient on medication and the side effects.
Risk of CHF.
Diet and Exercise.Balanced diet three times a day.Stop smoking.
Medication reconciliation done.
Pneumonia vaccine/flu vaccine given.
Is patient at risk for falls :No.
Suicidal risk: No.
Do patient have copy of advance Directive:No.
Copy of advance Directive on the chart.