Question

Concept Map

Twenty-five year old Mr. B is admitted to room 12A recurrent Tonsillitis. B/P= 111/78. TPR= 38.4 ° C-108-22.   Allergies=Penicillin (rash). Pt. c/o throat and ear pain 9/10 and swollen glands in jaw area. Pulse Ox 97% on room air. Respirations easy and unlabored.    A & O x 4.   States ↑ throat discomfort when speaking and inability to eat/swallow food or fluids for the past 48 hours. Tonsils moderately enlarged and reddened bilaterally, not obstructing airway. Halitosis noted. Color pink, skin warm & dry. Braden score 22. PERRLA. CR < 3 sec. Palpable peripheral pulses @+2 x 4. Past hx= appendectomy age 12. IV of 1000 ml D5W at 100ml/hr to left forearm ṡ redness or swelling. Urine dark yellow, voiding small amounts. Skin appears dry.

Dr’s orders:

Rapid strep test- notify MD of results stat

Urinalysis

Acetaminophen 650 mg liquid po q4h prn for pain or temperature > 38.5 ° C.          

Benzocaine (Chloraseptic) 1 throat lozenge q4h prn.

Diet-Full liquid

Activity: Up ad lib

Gargle with warm salt water tid

Call M.D. if pulse Ox < 95 %   

Lab work results:

Na+ 138; K+ 4.0; Cl- 98; BUN = 21; Creatinine= 1.5; Bicarb 22 Glucose= 110

WBC = 13,000, Hbg. 14, Hct=40% Plts.= 250,000. Calcium 9.6.

Primary Nursing Diagnosis

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Nursing Diagnosis #2

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Nursing Diagnosis #3

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EBP Citation:

Answer 1