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    Fae Nicole Mangiliman
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    A 58-year-old male was admitted to the hospital with pneumonia. He is ambulatory and able to speak with vital signs within normal limits except for an elevated temperature. He is receiving IV fluids and medications including antibiotics, steroids, and paracetamol as needed for fever. A chest x-ray and blood gas test were repeated and the patient is producing phlegm when coughing but can eat without restrictions. His condition was monitored during the nurse's shift and he had no complaints.

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    A 58-year-old male was admitted to the hospital with pneumonia. He is ambulatory and able to speak with vital signs within normal limits except for an elevated temperature. He is receiving IV fluids and medications including antibiotics, steroids, and paracetamol as needed for fever. A chest x-ray and blood gas test were repeated and the patient is producing phlegm when coughing but can eat without restrictions. His condition was monitored during the nurse's shift and he had no complaints.

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    6 views1 page

    Case Scenario

    Uploaded by

    Fae Nicole Mangiliman
    A 58-year-old male was admitted to the hospital with pneumonia. He is ambulatory and able to speak with vital signs within normal limits except for an elevated temperature. He is receiving IV fluids and medications including antibiotics, steroids, and paracetamol as needed for fever. A chest x-ray and blood gas test were repeated and the patient is producing phlegm when coughing but can eat without restrictions. His condition was monitored during the nurse's shift and he had no complaints.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Admitted a 58-year-old male with pneumonia.

    Patient is ambulatory and can speak with vital


    signs of T=38.3, PR-108, RR- 31, BP- 120/80 mmHg and pulse oxy of 93. With IVF of PNSS to
    KVO at the left arm. Patient is coughing with moderate amount of phlegm. Patient can eat
    anything without restrictions. For repeat chest x ray today and ABG this morning. Patient is
    receiving nebulization fluimicil due q6, and IV meds are ceftriaxone 1g (q8) and hydrocortisone
    100mg (q4) and paracetamol 300mg IV (prn if temp more than 37.9).

    Sample Charting
    Nurse’s Notes

    September 2, 2022 7:00 a.m. – 3:00 p.m.


    7:05 a.m.  Received the patient ambulatory, conscious and
    coherent
    8:00 a.m.  With an ongoing IVF of PNSS to KVO at the left
    BP – 120/80 mmHg arm
    RR – 31 cpm  Vital signs taken and recorded
    PR – 108 bpm  Maintained and re-instructed
    Temp. – 38C  CXRay and ABG repeated this morning
     Patient is given nebulization fluimicil due q6, IV
    meds are ceftriaxone 1g (q8) and hydrocortisone
    100mg (q4)
    3:00 p.m.  Paracetamol 300mg (prn if temp > 37.9)
     No complaints made during shift
     Kept monitored
     Needs attended
     Endorsed

    Fae Nicole Mangiliman / Alejandro B. Gigante RN/


    Student Nurse-Bulsu Clinical Instructor-Bulsu
    Batch 2024 Lic. #0000

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