MED-SURG EXAM ELABORATIONS
Carlos mancia, 48yr-old, spanish speaking migrant worker with no known past medical hx. R/o
tuberculosis. Vital signs -temp 99.1 f, 37.3 c, 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 maintenance 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 extension 61178. Dr. Rondeau - answer-carlos mancia room 301
Carlos mancia, 48yr-old, spanish speaking migrant worker with no known past medical hx. R/o
tuberculosis. Vital signs -temp 99.1 f, 37.3 c, 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 maintenance 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 extension 61178. Dr. Rondeau
Educational needs - increased acuity
Status assessment reports patient with airborne isolation and frequent reminders to stay in room and
maintain mask precautions.
Fall risk - increased acuity
Status assessment reports patient connected to iv line and as being fatigued which could result in fall.
Health change - increased acuity
Status assessment reports r/o tuberculosis, skin moist, bilateral wheezes/rhonchi sao2 91%, blood-
tinged/productive cough, fatigue/fear/concern.
Pain level - normal acuity
No indication of pain at this time.
Psychological - needs increased acuity
Status assessment reports spanish-speaking migrant, spanish interpreter available, expresses
fear/concern/desire for recovery.
Sensorium - normal acuity
Status assessment reports no indication of increased sensorium acuity. - answer-
Marcella como room 302
, Marcella como, 38 yr-old, sexual trauma victim (rape), unknown assailant. Non-significant past medical
hx. No known allergies (nka). Vital signs temp 98.2 f, 36.8 c, bp 94/60, p72, rr 22, sao2 99%. Multiple
abrasions, bruising head, chest, and inner thigh. Isolative, appears fearful, crying, and refusing to see her
husband. Sane nurse to make second visit today. Awaiting diagnostic labs. Taking hiv meds prophylaxis.
Social worker with patient this morning. Diet as tolerated. Dr. Roopes - answer-
Educational needs - increased acuity
Status assessment reports patient is a sexual trauma victim, taking hiv meds prophylaxis, social worker
with patient this morning.
Fall risk - normal acuity
Status assessment reports no indication of increased psychological acuity
Health change - increased acuity
Status assessment reports patient is a sexual trauma victim (rape), isolative, appears fearful/crying,
taking hiv meds prophylaxis.
Pain level - increased acuity
Patient has multiple abrasions and bruising.
Psychological needs - increased acuity
Status assessment reports patient is a sexual trauma victim (rape), isolative/fearful/crying, sane nurse
and social worker with patient.
Sensorium - normal acuity
Status assessment reports no indication of increased psychological acuity - answer-
Tom richardson room 303
Tom richardson, tom richardson 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa
drugs. Vital signs temp 98.4 f, 36.9 c,bp 178/105, p 112, rr 28, sao2 94%; neuro- wnl's. Skin warm and
pale. Generalized weakness, blood tinged urine and severe pain upon urination, gi- n/v. Clear liquid diet.
Strict i&o and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe
pain (10/10) medicated q 30 minutes x4 with iv morphine 2mg with little relief. Iv d5 1/2 ns @100ml/hr.
Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport." -
answer-
Educational needs - increased acuity
Status assessment reports patient had clear liquid diet, strict i&o, strain urine, lithotripsy treatment
ordered.
Fall risk - increased acuity
Status assessment reports patient has generalized weakness, patient medicated q 30 min x4 with iv
morphine 2mg with little relief.
Health change - increased acuity
Status assessment reports patient has urinary stones, generalized weakness, gi- n/v, clear liquid diet,
strict i&o, severe pain, stat lithotripsy treatment ordered.
