lOMoARcPSD|52942330
Week_2_Post_Clinical_MH_Clinical_
Worksheet_Nursing_Concepts_Herzing_
University
, lOMoARcPSD|52942330
Clinical Worksheet
Initia Diagnosis: Right HCP: MD Isolation: IV Type: Critical Labs: CBC Other Services:
lower lobe Jacob Jones Standard N/A with differential, Chest X-ray was
l: pneumonia ABGs and BMP, completed
Fall Location: Ultrasound, Blood
MH Length of Risk: Back of venous sample,
Stay: 6.2 Consults: Yes right hand Sputum specimen,
Age: days Respiratory Consults Needed:
Therapist Transf Fluid/Rate: N/A Respiratory
72 Allergies: er: Therapist
N/A
M/F:
F
Code Status: Full
code
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?:
The patient was diagnosed with right lower lobe pneumonia. The patient is a smoker and smokes half a pack a day. The patient is coughing up rust
colored sputum. Patient later developed deep vein thrombosis while admitted.
Health History/Comorbities (that relate to this hospitalization):
Former Smoker
Was diagnosed with influenza 10 days prior to admission and pneumonia diagnosis
Obesity (weight is heavy for someone who is 5’5”)
Shift Goals/ Patient Education Needs:
1. Educate patient on coughing
2. Encourage coughing
3. Educate patient on use of incentive spirometer
4. Educate patient on pneumonia
Week_2_Post_Clinical_MH_Clinical_
Worksheet_Nursing_Concepts_Herzing_
University
, lOMoARcPSD|52942330
Clinical Worksheet
Initia Diagnosis: Right HCP: MD Isolation: IV Type: Critical Labs: CBC Other Services:
lower lobe Jacob Jones Standard N/A with differential, Chest X-ray was
l: pneumonia ABGs and BMP, completed
Fall Location: Ultrasound, Blood
MH Length of Risk: Back of venous sample,
Stay: 6.2 Consults: Yes right hand Sputum specimen,
Age: days Respiratory Consults Needed:
Therapist Transf Fluid/Rate: N/A Respiratory
72 Allergies: er: Therapist
N/A
M/F:
F
Code Status: Full
code
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?:
The patient was diagnosed with right lower lobe pneumonia. The patient is a smoker and smokes half a pack a day. The patient is coughing up rust
colored sputum. Patient later developed deep vein thrombosis while admitted.
Health History/Comorbities (that relate to this hospitalization):
Former Smoker
Was diagnosed with influenza 10 days prior to admission and pneumonia diagnosis
Obesity (weight is heavy for someone who is 5’5”)
Shift Goals/ Patient Education Needs:
1. Educate patient on coughing
2. Encourage coughing
3. Educate patient on use of incentive spirometer
4. Educate patient on pneumonia
