care plan for this patient please include Assessment,diagnosis, outcome, intervention, and rational at least 5each
Jamie Thompson
38 year old female
Primary DX: Pneumonia
Secondary dx: UTI
HX: A-fib, asthma, HTN, Type 1 DM, paraplegia s/p MVA in 2018,smoker (12 yrs), hypothyroidism
Left forearm 20G IV
S/S – Fever, SOB, night sweats, productive cough x 1week
Chest x-ray – (+) for Right pneumonia
Covid swab – (+) Covid 19
Medications
Labetalol 20 mg once a day
Coumadin 6 mg once a day
Aspart insulin with meals on sliding scale
Albuterol 2.5 mg inhaler q 4 hours PRN
Tylenol 1000 mg q 8 hour PRN for Temp >100.4 or pain
Flexeril 10 mg q 6 hours
Mobility: wheelchair bound, independent, full movement andstrength in UE and paralysis to both LE
Foley catheter – chronic, urine is dark, cloudy and has odor
Incontinent of bowel and bladder
Wounds – Sacral stage III (collagenase, packed with aquacel andcovered with foam dressing), bilateral heels DTI (foamdressings)
Back pain – 6/10 – ache, chronic
Social – lives with brother in apartment in Manhattan. He is acorrections officer at Rikers Island. Brother is maincaregiver.
On 6L/min oxygen NC
Vitals
T- 101.9
HR -105
O2 – 90%
RR-24
BP- 130/68
