Please enable JavaScript.
Coggle requires JavaScript to display documents.
Weakness - Coggle Diagram
Weakness
Hx
Dysrhythmia
Tachycardia
Hypothyroidism
Gastroesophageal reflux
Confusional state.
Hypercholesterolemia
Constipation.
Hypertensive disorder
-
Long-term goals
Prevent UTI Manage electrolytes Keep stable the cardiovascular health and manage chronic conditions such as hypothyroidism, hypertension and hypercholesterolemia
Short- term goals
Improve body temperature Reduce UTI symptoms which will stabilize the shakiness, BP and HR. Management of sodium levels
Medications
Aspirin = 81 mg PO
Enoxaporin 60 mg = 0.6 mL Subq
Atorvastatin = 20 mg PO
cefTRIAXone = 1,000 mg PO
Levothyroxine = 50 mcg PO
Metropolol = 50 mg PO
Omega -3 = 1,000 mg PO
Labs
Eosinophils 5.4
Basophils 0.4
Sodium 132.2
Total CO2 21.7
Protein (URINE) trace
Occult blood (URINE) trace -- intact
RBC (URINE) rare
bacteria (URINE) 3+
Nitrites positive
Pt Education
Improve the understanding and to manage the chronic diseases. How to proper use the medications, maintain a good hydration and diet ( to prevent constipation as well)
interventions
Temperature needs to be monitored to prevent hypothermia, besides that, vital signs as well.
Administer antibiotics and keep using them until the recommended date by the provider
To have a better balance in the electrolytes she should have more fluid intake based on sodium levels.
Educate about UTI prevention, hydration, medication and diet changes (due to the history of constipation)
Assessment
no pain but annoyed that her hands are shaking so much
temperature keeps dropping even with blankets
BP= 126/62
Pulse = 62 bpm
Sitting
SpO2 98%
Room Air
RR 18 bpm
Pt is feeling better at 0722 than 0300 (which was when she was admitted)
Weight 55.1 kg
-