Question

Joseph Vojnovic is an 80-year old man admitted with diagnosis of possible pneumonia. He complains of general malaise and a frequent productive cough, worse at night. Vital signs T 38.5 C P 92 beats/min R 22 breaths /min BP 150/90 mmHg During your initial assessment he coughs violently for 40 to 45 seconds without expectorating. He exhibits coarse crackles and wheezes at both bases of the lungs. He states, “It hurts'in my chest when I cough.”

The nurse positions Mr Vojnivic in a semi-Fowlers position, encourages him to increase his fluid intake, and gives him acetominophen (tylenol)  650 mg po, as ordered for fever.  One hour later, the client is resting in bed

Vital signs are  T 37.7    P  86  R  22   BP 130/86

He states that he has been able to sleep. His fluid intake over the past hour has been 200 ml of water.

Near the end of the shift, you have identified fluid volume deficit as a nursing diagnosis for Mr. Vojnivic. Since his admission, he has a fluid intake of about 600 ml, and his urine output was 300 ml of dark, concentrated urine. His temperature is back up to T 38.4C, his mucous membranes are dry, and he states he feels very weak.

Several days later, after treatment with IV antibiotics, MrVojnovic is feeling much better, and preparations are bing made for discharge.

He is to take cephalexin (keflex) 500 mg every 6 hours, for the next 10 days; continue to drink extra fluids; and to get 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 one week from today and should call the physician if symptoms re-occur.

?) Write a discharge summary that is concise and instructive.

Answer 1

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