Problem: Infection Supporting: Evidence/ Data- Fever =Is

Problem: Infection Supporting: Evidence/ Data- Fever =Is evidenced by {Temperature 104.7} Patient white blood cell is Increased. Patient is positive blood for Staph. Patient is dehydrated. Vomit Nausea Sweating Medication /Intervention: The patient received Tylenol ordered by the M.D., for his fever and any antibiotic for the infection. I.V. fluid (normal saline) for dehydration. monitoring patients’, I&O for output. Hand wash PPE for isolation Monitoring the patient’s vital signs every hour Evaluations: The patient received Tylenol ordered by the M.D. which brought the fever down to Temperature (98.0 F) and received antibiotics for his infection. His white blood count is normal. Teach the patient about infection and the importance of washing hands. Teach the patient to drink fluids to be hydrated. Teach the patient any antibodies medication prescribed by the doctor and repeat it back to me. Make the patient comfortable. Problem 2 UTI Supporting Evidence / Data The patient has a determined urge to urinate and a burning sensation when urinating. Medication/Intervention: 1. Encourage the patient to drink a lot of fluids,2. Monitor labs such as WBC count, Urinalysis, 3. Medication- Ceftriaxone, which was ordered by M.D. To help the patient with the burning sensation and the bacteria in the urine Evaluation: Continue to monitor the patient’s vital signs every hour and communicate with the patient for any pain with urination or fever. monitoring patients’, I&O for output. Make the patient comfortable. Problem #3 Pneumonia: Supporting: Evidence/Data: Patient reports cough and having green phlegm. Saturation of oxygen O2 88. A physical exam notable crackles at the lung and the patient had a chest x-ray showing pneumonia productive of green phlegm. Physical exam notable for crackles at the lung bases. The patient’s chest x-ray showed pneumonia. Medication/Interventions: Administer medication of Azithromycin IV for pneumonia ordered by the M.D Monitor the patient’s O2 status. And give 2 L of oxygen. Educated patient on the need for deep breathing and coughing. Teach the patient how to use an incentive spirometer. Evaluation: Patient oxygen saturation is above 95 %on room air. The patient verbalizes understanding deep breathing is important and how to use the incentive spirometer which helps him breathe better. The patient is not in any pain and the patient is in a comfortable position with the head of the Bed at 45-60 degrees. Problem #4 Hypertension Supporting /evidence/Data: The patient’s Blood pressure is 145/90 which shows elevated blood pressure. Medication:/ intervention: Administer medication: Amlodipine 5mg PO daily as prescribed by M.D Educated the patient on high blood pressure. Educated on the patient how to check their blood pressure at home. Educated the patient to have a record book and check their blood pressure often. Educated patient on lifestyle and diet modification. Evaluations: Blood pressure is controlled at 125/72mmHg. The patient verbalized understanding of keeping a blood pressure book. The patient demonstrated how to use blood pressure at home. Teach the patient the importance of diet and lifestyle changes. Reasons for needing healthcare: The patient GR came to the ER for Infection, and report SOB for 3 days. Associated with cough and phlegm, and chest pain. Medical Diagnosis / Surgical procedure: Pneumonia. The patient has a past medical history of hypertension and HIV. if I did the concept map correctly.

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