1. Joseph Page is an 80-year-old man admitted with a diagnosis of possible pneumonia. He complains of general malaise and a frequent productive cough, worse at night. Vital signs are as follows: blood pressure, 150/90 mm Hg; pulse rate, 92 beats per minute; respirations, 22 breaths per minute; and temperature, 38.5° C (101.3° F). During your initial assessment he coughs violently for 40 to 45 seconds without expectorating. His lungs have wheezes and rhonchi in both bases and are otherwise clear. He states, “It hurts in my chest when I cough.”
differentiate between objective and subjective data in this case example
You position Mr. Page in a semi-Fowler’s position, encourage increased fluid intake, and give Tylenol 650 mg by mouth (PO) as ordered for fever. One hour later the client is resting in bed. Vital signs are as follows: blood pressure, 130/86 mm Hg; pulse rate, 86 beats per minute; respirations, 22 breaths per minute; and temperature, 37.7° C (99.8° F). He states he has been unable to sleep and feels very weak. You also note that his mucous membranes are dry. His fluid intake has been 200 mL of water in the past 8 hours.
*** Use the given information to write a nurse’s progress note using the PIE format. (30 points)
Several days later, following treatment with intravenous antibiotics, Mr. Page is feeling much better and preparations are being made for discharge. He is to take Keflex 500 mg PO every 6 hours for the next 10 days, continue to drink extra fluids, and get extra rest. He lives alone. Although he is generally cooperative, he does not like drinking water or taking pills. He is to make an appointment with his physician for 1 week from today and should call the physician if he develops symptoms of recurrence.
*** Write a discharge summary that is concise and instructive. (10 points)
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