Millie Larsen VSIM 보고서

목차

1. 사례 정보
2. Documentation Assignments
3. Reflection Questions

본문내용

이 름 : Millie Larsen
성 별 : W/84
진단명 : urinary tract infection

기 타 : 키/몸무게: 155cm/68kg
과거력: elevated blood pressure, high cholesterol, glaucoma, arthritis (right knee)
BP:180/110mmHg▲, pulse:120/분▲, RR:16/분, T:36.9, SPO2: 97%
폐음: 양쪽 normal, 심음: normal
식욕: normal, NRS: head 4점
Chemistries: sodium-149mEq/L▲, potassium-3.2mEq/L▼
CBC: WBC-12000▲, Hemoglobin –11g/dL▼
urine analysis: urine color- Dark amber, cloudy, specific gravity- 1050▲
red blood cells- 9HPF▲, white blood cells- 50HPF▲
SPICES: incontinence, confusion

출처 : 해피캠퍼스