R.W, 69, C1, Female
by Fatima Ahmed
1. Allergies: Penicillin
1.1. Rash
2. Hypertension
2.1. Losartan
3. Chronic Pain
3.1. 4/10 with Meds
3.2. 9/10 on admission
3.3. Dilaudid
3.4. Morphine (Contin & Statex)
4. Hernia Repair
5. Admitting Diagnosis
5.1. Left Breast Mastectomy (2015)
5.2. Stage IV Breast Cancer with Liver Metastasis
5.2.1. Dexamethasone
5.2.2. Zoledronic Acid
6. Diagnostic Test
6.1. BUN - 24 ↑
6.2. BUN Creatinine Ratio - 14.3 to 1 ↑
6.3. Protein Total - 6.1
6.4. Bilirubin Total - 0.2 ↓
6.5. ALK - 164 ↑
6.6. AST - 44 ↑
6.7. ALT - 50 ↑
6.8. Creatinine - 1.0
7. SDOH
7.1. Educated; Masters in Social Work
7.2. Retied with husband; financially stable
7.3. English spoken
7.4. Cared for by family; CAREGIVER BURDEN
8. Strengths
8.1. Good social support with husband and son; visits daily.
9. Learning Needs
9.1. Nutrition deficit
9.2. Hopelessness
10. Socioeconomic
10.1. Married and living at home with her husband. They are financially stable and retired. Her son visits daily.
11. HC Provider Orders
11.1. Diet: DAT
11.2. Bed rest with 1PA
11.3. O2 Sat Monitoring - 2L
11.4. Falls precaution
12. PHCP
12.1. Health Promotion
12.2. Public participation
13. Cultural Safety
13.1. Black/African American
13.2. Christian
14. Complications
14.1. Pain
14.2. Weak/Fatigue
14.3. Decreased Appettite
15. Mental Health
15.1. Anxiety
15.1.1. Death?