Question

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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.

Client Initials _______ Date ________

Age _____ Gender _____ Room # _____   Admit Date __________

CODE Status __________ Allergies _____________________________________

Diet _________ Activity __________ Braden Score __________

Admitting Diagnoses/Chief Complaint:

Assessment Data:

Medications:

IV Sites/Fluids/Rate:

Past Medical /Surgical History:

Lab Values/Diagnostic Test Results:

Treatments:

Primary Nursing Diagnosis

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

              

Nursing Diagnosis #2

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

Nursing Diagnosis #3

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

EBP Citation:

Answer 1

Client Initials: Mr.B Date N/A

Age: 25 years Gender:male Room # 12A Admit Date : N/A

CODE Status N/A Allergies: Penicillin

Diet : Full liquid diet

Activity: No restrictions

Braden Score : 22 No risk for pressure ulcer

Admitting Diagnoses/Chief Complaint: Recurrent tonsillitis

Assessment Data:

Chief complaints: Throat and ear pain with dysphagia

Present illness history : Throat and ear pain and swollen glands in jaw area. Increased throat discomfort when speaking and inability to eat/swallow food or fluids for the past 48 hours.

Surgical history: Appendectomy at 12 years of age

Medical history: Respirations easy and unlabored. Peripheral pulses are palpable, Normal pulse, no arterial disease, no reduction in arterial flow. Skin pink, warm and dry. Tonsils moderately enlarged and reddened bilaterally. Halitosis present. Patient voids less urine dark color . Dysphagia present with no intake of food and liquids.

Family history: N/A

General - NAD

Eyes - PERRLA

ENT - Swollen salivary glands in jaw and moderate enlargement of tonsils bilaterally with redness. Halitosis present. Dysphagia present. Pain scale: 9/10

Neck - swelling seen

Lymph Nodes - No lymphadenopathy

Cardiovascular - Tachycardia, no JVD, no carotid bruits .

Lungs - Clear to auscltation, no use of accessory muscles, no crackles or wheezes.

Skin - No rashes, skin warm ,pink and dry, no erythematous areas

Abdomen - tender with increased bowel sounds

Genito Urinary – Dark yellow urine .Less quantity.

Rectal – Rectal exam not performed since no symptoms indicated blood loss.

Extremeties - No edema, cyanosis or clubbing. Peripheral pulses palpable with capillary refilling time more than 3 sec .

Musculo Skeletal - 5/5 strength, normal range of motion. Swelling and redness in left forearm.

Neurological – Alert and oriented x 4 patient is alert and oriented to person, place, time, situation.

Vital signs: BP= 111/78 mm hg T:38.4 ° P: 108 beats/ min R : 22 breaths / min SPO2 : 97% room air

Medications:

Acetaminophen 650 mg liquid po q4h prn if temperature is more than 38.5 ° C and increased pain .

Benzocaine (Chloraseptic) 1 throat lozenge q4h prn.

IV Sites/Fluids/Rate:IV of 1000 ml D5W at 100ml/hr to left forearm

Lab Values/Diagnostic Test Results:

Serum electrolytes:

Na+ 138; K+ 4.0; Cl- 98,

  

Serum calcium: 9.6

Blood chemistry:

BUN = 21; Creatinine= 1.5; Bicarb 22 Glucose= 110

CBC:

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

Treatments:

Gargle with warm salt water tid.

Full liquid diet

Primary Nursing Diagnosis:

• Deficient fluid volume related to swelling and pain in throat evidenced by dark urine in low amounts
• Acute pain related to swelling and pain in throat and ear evidenced by pain scale score of 9