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  • Subjective Objective Assessment Plan Vital Signs

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    -Lauяeиs© Tolosa
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    The patient is a 74 year old male experiencing night sweats with a fever over 99 degrees. On examination, he appears pale and fatigued with a yellow nasal discharge. Lung auscultation reveals crackles in both lungs, and an x-ray shows faint white streaks in both lungs. The assessment is community acquired pneumonia, likely viral. The plan is to provide supplemental oxygen, antiviral medication, nebulizers, bronchodilators and coughing exercises to clear secretions and improve airflow.

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    cap RT

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    CAP SOAP

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    The patient is a 74 year old male experiencing night sweats with a fever over 99 degrees. On examination, he appears pale and fatigued with a yellow nasal discharge. Lung auscultation reveals crackles in both lungs, and an x-ray shows faint white streaks in both lungs. The assessment is community acquired pneumonia, likely viral. The plan is to provide supplemental oxygen, antiviral medication, nebulizers, bronchodilators and coughing exercises to clear secretions and improve airflow.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    18 views2 pages

    Subjective Objective Assessment Plan Vital Signs

    Uploaded by

    -Lauяeиs© Tolosa
    The patient is a 74 year old male experiencing night sweats with a fever over 99 degrees. On examination, he appears pale and fatigued with a yellow nasal discharge. Lung auscultation reveals crackles in both lungs, and an x-ray shows faint white streaks in both lungs. The assessment is community acquired pneumonia, likely viral. The plan is to provide supplemental oxygen, antiviral medication, nebulizers, bronchodilators and coughing exercises to clear secretions and improve airflow.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    SUBJECTIVE I am experiencing night sweats with high fever GT 74 male

    OBJECTIVE Vital signs: BP: 122/72 mmHg RR: 16 bpm PR: 72 bpm Temp: 99.30F Spo2: 87% Inspection: Pale Easy fatigability Yellowish nasal discharge Diaphoretic Poor appetite Weight loss Palpation: Decreased tactile fremitus, both lungs basilar area Percussion: Dull percussion note on both lungs lower lobe Auscultation: Late inspiratory crackles on both lungs, basilar area X-RAY: Faint, widely scattered white streaks or patches

    ASSESSMENT

    PLAN

    >low grade fever /chills >mild hypoxemia

    >give anti-pyretic > supplemental oxygen 1lpm via NC >encourage to increase fluid intake

    Ineffective airway clearance related to ineffective cough and infection

    >probable sinus infection

    Diagnosis: Community acquired pneumonia t/c viral

    >have adequate rest & sleep >steam inhalation / nasal spray >give decongestants as prescribed >Diet as tolerated >increase intake of citrus fruits >nebulize bronchodilator q60 >nebulize mucolytics q120 >administer antiviral drugs as prescribed >bronchial tapping post neb >encourage to do deep breathing exercise >encourage to increase fluid intake to loosen secretion / to thin mucus >teach coughing exercise

    >consolidation of secretion

    >consolidation of secretion

    >ineffective airway clearance >pooling of secretions >pneumonia probably viral

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