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PATIENTS INITIALS: A.G.

F AGE: 36 years old CATEGOR#: 1 GENDER: Female ROOM NO$:

MEDICAL DIAGNOSIS: Meningtis Hypothyroidism ASIS !OR PRIORITI"ATION: Maslows Hierarchy of Needs DATE ADMITTED: January 8, !1 ST%DENT N%RSE: "#N $$$%& Grou' 1 NDx 4: Risk for fall related to possible occurrence of fall Objective Data: Vital Signs T: 36.4C HR: 75bpm RR: 16cpm Pain Scale: 6 1! "ge: #6 years old )*+("RT o )nset: ,radual o *ocation: Head Rig-t ear o +uration: (ontinuous o (-aracteristic: .nife%like o "ggravating factor: e/ertion of effort o Relieving factor: rest and medication $0& -ead and rig-t ear pain $0& 1acial grimace Rapid capillary refill *imited R)2 $0& Restlessness $0& decrease -earing on t-e rig-t ear "lert3 conscious3 oriented to # sp-eres (ontraptions o Heplock 2edications o (eftria/one o +ecilore o +e/amet-asone o "cyclovir

NDx 2: #ltered tissue perfusion cerebral" related to cerebral edema$ increased %C&. Objective Data: Vital Signs T: 36.4C HR: 75bpm RR: 16cpm Pain Scale: 6 1! "ge: #6 years old )*+("RT o )nset: ,radual o *ocation: Head Rig-t ear o +uration: (ontinuous o (-aracteristic: .nife%like o "ggravating factor: e/ertion of effort o Relieving factor: rest and medication $0& -ead and rig-t ear pain $0& 1acial grimace Rapid capillary refill *imited R)2 $0& Restlessness 2edications o (eftria/one o +ecilore o +e/amet-asone o "cyclovir

NDx 3: Impaired skin integrity related to immunological deficit as evidenced by


pruritus in forearms and chest with multiple white macules

Objective Data: Vital Signs T: 36.4C HR: 75bpm RR: 16cpm Pain Scale: 6 1! "ge: #6 years old $%& s'elling $%& redness History of parathyroid surgery last 2006
hypothyroidism !" hypothyroidism

(ontraptions o Heplock

ND& ': Acu(e 'ain rela(ed (o headache secondary (o menin)eal irri(a(ion as e*idenced +y 'ain scale of 6,1!
Objective Data: Vital Signs T: 36.4C HR: 75bpm RR: 16cpm Pain Scale: 6 1! "ge: #6 years old )*+("RT o )nset: ,radual o *ocation: Head Rig-t ear o +uration: (ontinuous o (-aracteristic: .nife%like o "ggravating factor: e/ertion of effort o Relieving factor: rest and medication $0& -ead and rig-t ear pain $0& 1acial grimace Rapid capillary refill *imited R)2 $0& Restlessness $0& decrease -earing on t-e rig-t ear "lert3 conscious3 oriented to # sp-eres (ontraptions o Heplock 2edications o (eftria/one o +ecilore o +e/amet-asone o "cyclovir

MEDICAL DIAGNOSIS: 2eningitis Hypot-yroidism KEY ASSESSMENT: Vital Signs P-ysical "ssessment $especially skin and ,IT& "ge +iet 2edications (ontraptions *evel of consciousness +evelopmental age History of past illness 1amily History