please fill the chart do not write a word document, and do 3 med cards choose any three you want and fill out the SBAR paper
DL 75 yo male
Admitted with RLL pneumonia and fatigue
Admitted with RLL pneumonia and fatigue
Symptoms – SOB, fatigue , loss of appetite , difficulty breathing x 2 days.
PMH – DM type 2 , hypercholesteremia, Vit D def, HTN, GERD
PSH – Total Right Hip Replacement 6/2019
Cholecystectomy 6/2018
Vital Signs: BP: 127/68 T-100.0, P-102, R-24, Oxygen Saturation-93% on 2L NC
Social history – retired chef , 3 grown children , married 45 years , denies alcohol, drugs and/or smoking
Meds :
1. Metformin 500 mg po BID
2. Vit D 50,000 IU once a week
3. Lisinopril 10 mg po QD
4. Atorvastatin 20 mg po QHS
5. Januvia 10 mg po QD
6. Aspirin 81 mg po QD
7. Prilosec 40 mg po QD
DOB 12/5/45
Weight/ height. 211 pounds 6 feet
Sex – male
NKDA
DNR/DNI
DIET- Regular
Nursing care – OOB to chair with assistance
Incentive Spirometer Q 10 minutes
Chest PT
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