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Patient: JV - Coggle Diagram
Patient: JV
Nursing Interventions:
High flow non-rebreather mask for oxygen.
Tele for cardiac.
ICU transfer: initiate sepsis protocol.
Give patient IV fluids 0.9 normal saline.
Reposition patient every 2 hours to avoid pressure ulcers.
Administer antibiotics to prevent infection.
Check lung sounds for patient every hour.
Monitor intake and output (urine)
Patient will demonstrate improved ventilation and oxygenation of tissues by the ABG's
Patient will maintain optimal gas exchange.
Assessment
Neuro: A/O 2-3
GI: last BM: 2 days ago.
GU: 20 ML output in 3 hours.
Musculoskeletal: Non remarkable. Patient able to ambulate. Range of motion intact.
Skin: warm and dry: Left wrist IV. temperature: 102.5
Cardiac/Respiratory: BP: 84/36 RR: 28 crackles and wheezes in lungs, HR: 120 O2: 92% on 6 L.
Primary Diagnosis: Pneumonia.