Scribd Logo
Upload

Welcome to Scribd!

  • 6 views

    Case-Study - UMALI-M A V

    Uploaded by

    Mikes Castro
    This case study document contains information about a patient named Rodel Melson. It includes his vital signs, medical history, treatment plan, and medications. The focus of care for Mr. Melson has been his impaired skin integrity and alteration in comfort from a laceration on his left heel. Nurses have been monitoring his vital signs, providing IV fluids and pain medication, and ensuring a therapeutic environment for healing. The attending physician is Dr. Ciabal and Mr. Melson's medications include Levofloxacin, Clindamycin, and Celebrex based on the final diagnosis of a laceration on his left heel.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content

    You might also like

    Case-Study - UMALI-M A V

    Uploaded by

    Mikes Castro
    6 views13 pages
    This case study document contains information about a patient named Rodel Melson. It includes his vital signs, medical history, treatment plan, and medications. The focus of care for Mr. Melson has been his impaired skin integrity and alteration in comfort from a laceration on his left heel. Nurses have been monitoring his vital signs, providing IV fluids and pain medication, and ensuring a therapeutic environment for healing. The attending physician is Dr. Ciabal and Mr. Melson's medications include Levofloxacin, Clindamycin, and Celebrex based on the final diagnosis of a laceration on his left heel.

    Original Description:

    Original Title

    Case-Study_UMALI-M.A.V.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This case study document contains information about a patient named Rodel Melson. It includes his vital signs, medical history, treatment plan, and medications. The focus of care for Mr. Melson has been his impaired skin integrity and alteration in comfort from a laceration on his left heel. Nurses have been monitoring his vital signs, providing IV fluids and pain medication, and ensuring a therapeutic environment for healing. The attending physician is Dr. Ciabal and Mr. Melson's medications include Levofloxacin, Clindamycin, and Celebrex based on the final diagnosis of a laceration on his left heel.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    6 views13 pages

    Case-Study - UMALI-M A V

    Uploaded by

    Mikes Castro
    This case study document contains information about a patient named Rodel Melson. It includes his vital signs, medical history, treatment plan, and medications. The focus of care for Mr. Melson has been his impaired skin integrity and alteration in comfort from a laceration on his left heel. Nurses have been monitoring his vital signs, providing IV fluids and pain medication, and ensuring a therapeutic environment for healing. The attending physician is Dr. Ciabal and Mr. Melson's medications include Levofloxacin, Clindamycin, and Celebrex based on the final diagnosis of a laceration on his left heel.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 13

    NCM 107 RLE November 13, 2022

    Case Study
    ed
    Present
    : U m a l i,
    by
    e
    Marionn
    a n d r a V.
    Alex
    NCM 107 RLE November 13, 2022

    Table of Contents

    1 Patient's Information 3 Treatment/Medication (Drug Study)

    2 FDAR (Focus, Data, Action, & Response)


    NCM 107 RLE November 13, 2022

    Patient's Information
    NCM 107 RLE November 13, 2022

    Information of the Patient

    Name of Patient: Attending


    Physician: Medicines:
    Rodel, Melson Levofloxacin
    Dr. Ciabal
    Room #: Clindamycin
    Final Diagnosis: Celebrex
    N203
    Laceration of Left
    Age: Heel
    37 years old
    Sex:
    Male
    NCM 107 RLE November 13, 2022

    FDAR
    Name of Patient: Rodel, Melson Age: 37 years old Attending Physician: Dr. Ciabal
    Date & Time
    FOCUS DATA ACTION RESPONSE
    of Shift

    11/08/22 • Impaired Skin Vital Signs 1. Patient assessed Vital Signs


    6:00pm Integrity • BP: 100/60 and identified • BP: 100/70
    mmHg 2. Vital signs taken • Temperature:
    • Temperature: and recorded 36.7 °C
    36.2°C 3. IVF checked • CR: 72 bpm
    • CR: 60 bpm 4. Received D5LR • RR: 23 bpm
    • RR: 21 bpm 1L every 8 hours • For surgery
    • conscious and 5. Diet as tolerated • Waiting for
    coherent 6. Therapeutic Dr.'s rounds
    environment
    Input:
    provided
    • Urine: 510 mL

    11/08/22
    9:41 pm
    Name of Patient: Rodel, Melson Age: 37 years old Attending Physician: Dr. Ciabal
    Date & Time
    FOCUS DATA ACTION RESPONSE
    of Shift

    11/09/22 • Alteration in Vital Signs 1. Patient assessed Vital Signs


    6:00pm comfort • BP: 120/80 and identified • BP: 110/80
    mmHg 2. Safety secured mmHg
    • Temperature: 3. V/S taken and • Temperature:
    36.3°C recorded 35.6 °C
    • CR: 74 bpm 4. Needs attended • CR: 66 bpm
    • RR: 22 bpm • RR: 15 bpm
    • Afebrile • Afebrile
    •Patient is
    conscious and
    coherent

    11/09/22
    9:41 pm
    NCM 107 RLE November 13, 2022

    Treatment/
    Medications
    Home Medications and Instructions on
    Administration
    MEDICINES

    1. Levofloxcin 1 2
    500mg/cap
    —Give 1 cap 2x a day x
    15 days (oral at 8am)
    2. Clindamycin
    300mg/cap
    —Give 1 cap 2x a day x
    15days (oral at 8am) 3
    3. Celebrex 200mg/cap
    —Give 1 cap 2x a day x 7
    days (oral at 8am)
    Treatment/Medication
    Treatment/Medication
    Treatment/Medication
    Prepared by: UMALI, M.A.V. November 13, 2022

    Thank you for


    listening!

    You might also like