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Ms. RG, 85 year old female |
End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement |
Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours |
CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/ L K: 4.0 mEQ/ L Cr: 1.2 mg/ dL Glucose: 200 mg/ dL BUN: 25 mg/ dL WBC: 6800/ mm/3 Hgb: 11.5 g/dL HCT: 34% PLT: 200000 PT- 18 aPTT: 25 seconds |
Patient had restful shift; needs dressing change to pressure injury on coccyx. Planned transfer back to SNF tomorrow. |
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Subjective: 85 year old female with s/p right lobectomy 1 year ago and s/p trach placement.
Objective: Sodium 138 mEq/L, chloride 90 mEq/L, potassium 4 mEq/L, creatinine 1.2 mg/dl, glucose 200 mg/dl, BUN 25 mg/dl, WBC 6800/mm3, HgB 11.5 g/dl, HCT 34%, PLT 200000, PT 18, aPTT 25 s.
Assessment:
1. End-stage COPD
2. Pressure injury- stage 3
Plan:
• Vital signs q4H
• NPO
• Trach care every shift or as needed
• Trach mask to 50% humidified O2
• Wet to dry dressing to coccyx every shift
• IV D5 ½ NS at 100 ml/hour
• IV Cefazolin 1g in 100 ml of D5W q8H
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...