Nurses’ Note: 1700-Mr. Grant is a 58-year-old

Nurses’ Note: 1700-Mr. Grant is a 58-year-old male admitted to the medical surgical floor from a long-term health care facility. He presented to the emergency department with severe pain and hypertension. He has a history of hypertension, obesity, and decreased mobility. Upon nurse’s physical assessment, a stage IV pressure ulcer was noted on the client’s sacral area. Vital Signs: 1700 Blood pressure 170/89 mm Hg Heart rate 122 beats per minute, regular Respiratory rate 26 breaths per minute. Oxygen saturation 94% on room air Temperature 100.6 oral Pain 9 out of 10 Diagnostic Tests CT of pelvis Bone infection noted in sacral area. Laboratory Values: 1700 RBC 5.1 mcL WBC 19,000 mm3 HCT 45% HGB 15 g/dL Platelet 200,000 mm3 Sodium 149 mEq/L Potassium 4.9 mEq/L Glucose 114 mg/dL BUN 16 mg/dL Creatinine 1.0 mg/dL Medications Orders Vancomycin 500mg IV every 12 hours after blood cultures and wound cultures obtained Metoprolol 25mg PO twice daily. Hold for blood pressure less than 110/ 60 mm Hg or heart rate less than 55 Morphine 2mg IV PRN pain greater than 7 Acetaminophen 650mg PO PRN pain 3-6 Focused Assessment Findings Skin Warm, dry, prolonged turgor. Sacral wound noted stage IV

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