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Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch an...

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33 pages

Written in 2023/2024

Grade A+

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Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. T...

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45 pages

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