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Assigning Acuity 1. Arthur Thomason Room 301
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 confused, but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated,
Respiration’s at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 ( Hypocapnia). Mr Thomason is anxious and from the shift before is obviously worsened in overall condition. • Educational Needs- Increased acuity
• Health Change- increased acuity
• LOC- increased acuity
• Pain Level- increased acuity
• Psychological Needs- normal Acuity
• Safety- increased acuity
2. Carlos Mancia Room 302
Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. r/o Tuberculosis. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Airborne Isolation. Neuro WNL. Skin moist, respiratory bilateral wheezes and rhonchi. Blood-tinged mucous, productive cough. Diet as tolerated. IV maintance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Expresses fatigue, fear, concern, and desire for recovery. Need frequent reminder to stay in room and maintain mask precautions. If family/visitors come, will need education to airborne precautions. Spanish interpreter available at ext: 61178. Dr. Rondeau • Educational Needs- Increased acuity
• Fall Risk- Increased acuity.
• Health Change-Increased
• Pain Level- Normal
• Psychological Needs-Increased acuity
• Sensorium-Normal acuity
3. Estelle Hatcher Room 303
Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs – Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV maintance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with minimal assistance. Family at beside. Dr Sangerstien • Educational Needs- Increase
• Fall Risk-increase
• Health Change- Increase
• Pain Level- Increase
• Psychological Needs- Normal
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