Infection

Impaired Gas Exchange

Hx of pneumonia, non productive cough,

lethargy

Hx of pneumonia, emphysema, COPD

Vital signs q4h HOB 30o 1L via NC

WBC 12.5 (3.8-11.2), segs 87

RR 18, regular, O2 saturation 96, 37.5 oral

158/70 66 (baseline)

Ceftriaxone 1G in D5W 50
Doxycycline 100 mg in ns

Left lower lobe fine crackles

RUL, RML, RLL, LUL clear
Coarse asymmetric pulmonary infiltrates
LLL

Negative sputum culture, 37.5 oral

Altered hemodynamic status

Deficient Knowledge

HTN
158/70 66
NSR, S1 S2

Chief Medical Diagnosis:

LLL Pneumonia
Priority Assessments:
Vital signs, O2 saturation, lung sounds,
neuro checks

Dementia
Poor historian
Lack of knowledge regarding
hospitalization

Altered skin integrity

Immobility

Skin breakdown on elbow and back

Imbalanced nutrition: less than

body requires

Multiple ecchymosis on arms, bilateral

BMI 16.1 (underweight)

Anorexia
Skin tenting

Immobility

Hx osteoarthritis
Bed rest
Fall precautions
Lethargy fatigue

Enoxaparin 30 mg sub q
PT/OT