VSIM Henry Williams 보고서

목차

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

본문내용

1. 사례 정보
이 름: 0000 Williams
성 별 : M / 69
진단명 : COPD exacerbation
기 타 :
신체계측 : 183cm 88kg
생년월일 : 1954.03.01
Hx : COPD, coronary artery disease
Allergy : Penicillin
입원 경로 : ER
주호소 : During the night with progressive shortness of breath.
V/S : 134/88-112-28-37.1-82%
(oxygen saturation has improved and is now running 88% on oxygen 2L/min by nasal cannula)

PH
7.34 ▼
PCO2
50 ▲
HCO3-
27 ▲
PO2
88 ▼
ABGA

CBC
WBC
11,800 ▲
HB
10 ▼

Radiology (Chest X-ray)
– There is hyperinflation, but no evidence of pneumothorax.
– The heart is nor enlarged.
– There are no signs of congestive heart failure
– The mediastinum is normal
2. Documentation Assignments

1
Document your assessment findings regarding the patient’s indivisual aging pattern and functional status.

출처 : 해피캠퍼스