Question: What Are The Assessment: Subjective And Objective Data, Nursing Diagnosis, Outcomes, Interventions, Rationales For The Interventions And Evaluation Of This Patient?

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 1 week 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 q8 hour PRN for Temp >100.4 or pain Flexeril 10 mg 96 hours Mobility: wheelchair bound, independent, full movement and strength 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 and covered with foam dressing), bilateral heels DTI (foam dressings) Back pain – 6/10 – ache, chronic Social – lives with brother in apartment in Manhattan. He is a corrections officer at Rikers Island. Brother is main caregiver. On 6L/min oxygen NC Vitals T- 101.9 HR-105 02- 90% RR-24 BP-130/68