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One Nurse Note for Carlos Mancia, Joyce Workman Sarah Kathryn Horton

Carlos Mancia

48yr-old, Spanish speaking migrant worker with no known past medical Hx. r/o Tuberculosis. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Airborne Isolation. Neuro WNL. Skin moist, respiratory bilateral wheezes and rhonchi. Blood-tinged mucous, productive cough. Diet as tolerated. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Expresses fatigue, fear, concern, and desire for recovery. Need frequent reminder to stay in room and maintain mask precautions. If family/visitors come, will need education to airborne precautions. Spanish interpreter available at extension 61178. Dr. Rondeau

 

Sarah Kathryn Horton

25 -year old graduate student was brought to the emergency room via ambulance after being shot on the local college campus. Sarah was admitted to Med-Surg at 2am. She has two through and through gun-shot wounds. One to her right thigh and one to her right shoulder. She has a 20- gauge peripheral IV to left forearm with 75 mL/hr. of 0.9% saline infusing. Vital signs are stable at this time, alert and oriented x3, reports pain 6/10. She remains tearful and has been told that her best friend died on the scene.

 

Joyce Workman Scenario 1

Mrs. Workman presented to the diabetes clinic and provided a 24- hour food recall. She was then sent to the lab for ordered lab tests. She is to notify the nurse upon return to the clinic from the lab. Patient has requested more information on her diabetes and states she does not understand why she “should be concerned” with blood glucose control in both the short and long term.

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 1206