https://padlet.com/greenapple1998/maddiepalmerconceptmap2 Clinical Shift: March 8th en-us 2019-03-11 20:05:01 UTC 2019-03-16 02:56:20 UTC hello@padlet.com greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340154033 2019-03-11 20:05:48 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340154033 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340155169 1. Vitals Q4H: 
BP: 142/82 Temp: 37 C Pulse: 89 Resp: 20 O2: 93
2. Tests ordered: no recent tests
3. Recent labs:
Hgb 12.5: normal range for men is between 13.5-17.5
Hct 37:  normal range for men is between 45-52%
Platelets 287: normal range is between 150-450
4. Trending analysis of vitals: O2 tends to dip into 87+ range throughout the night which could be due to COPD -- we provided a nebulizer treatment in order to open up his airways
5. Collaborations with others: being treated under Frank's service; also seen by respiratory therapist for COPD ]]> 2019-03-11 20:10:15 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340155169 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340162643 Abnormal labs: 
-Hgb is slightly low; this could be due to blood loss during surgery (only 15 hours post op)
-Hct is also low; Again, could be due to surgery. Also could be because patient had been on IV fluids and consuming a lot of water throughout the night
-BP was slightly high. Likely due to pain score of 6/10 and anxiety. 
-Respirations were on the higher end all night. Likely due to pain and difficulty breathing with COPD complications
-Mews score of 1 because of respiratory rate. This number is not considered abnormal because it is less than 3, but it is something to keep an eye on.]]> 2019-03-11 20:38:25 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340162643 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340168956 1. Zofran 4 mg IV q6h PRN
-Patient teaching: take with full glass of water; can be taken with or without food 
-Intended effect: to reduce nausea
2. Heparin 5,000 units SQ q 8-12 hr
-Patient teaching: use soft toothbrush, observe for signs of excessive bruising and bleeding
-Intended effect: prevent post-surgical DVT
3. Tylenol 1,000 mg PO q6h PRN
-Patient teaching: keep on schedule to help with best pain relief, do not take more than recommended daily dosage
-Intended effect: reduce pain, lower fever
4. Cefazolin 1 gram IV q8h for 24 hours (3 doses)
-Patient teaching: monitor for IV site reaction, may cause nausea
-Intended effect: to prevent/treat infection
5. Ipratropium albuterol 0.5 mg (Ipratropium) 2.5 mg (albuterol) mg / 3 mL nebulizer 4x daily PRN
-Patient teaching: take slow deep breaths, may cause increased HR
-Intended effect: to open airways and increase oxygenation ]]> 2019-03-11 20:56:55 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/340168956 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341940718 S: anxiousness, nausea, dizziness, pain rating 6/10 initially, then reduced to 4/10, bladder spasms
O: vomiting, tachypnea (resp 20), 6 small laparoscopic incisions -- clean, dry, intact 
PMH: Meniere's disease, anxiety, COPD]]> 2019-03-15 21:47:09 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341940718 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341942560 -Patient goal: To use the incentive spirometer 10x per hour followed by coughing and deep breathing by end of shift. Goal was achieved by using it often and demonstrating that he understood how to correctly use it.
-Patient teaching: demonstrate how to use the incentive spirometer, explain that the goal is to inhale while using it vs exhale 
-Potential complications: pneumonia, prolonged hospitalization due to O2 dependence]]> 2019-03-15 22:02:33 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341942560 greenapple1998 https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341959183 -Patient goal: To communicate concerns with healthcare team during rounds at end of night shift/beginning of dayshift. Goal was met by asking the resident about questions that were brought up throughout the night.
-Patient teaching: relaxation techniques, offer distraction, keep him informed of health status throughout hospital stay
-Potential complications: increased anxiety and worrying]]> 2019-03-16 01:15:42 UTC https://padlet.com/greenapple1998/maddiepalmerconceptmap2/wish/341959183