Patient: Indira Desai
by Autumn Hirsch
1. Vital Signs
1.1. Temp: 100.5 F
1.2. RR: 30
1.3. P: 110
1.4. B/P: 142/90
1.5. Pain rating: 3/10
1.6. O2 Stat: 98
2. Primary Dx: Cellulitis R/T dog bite
2.1. Antibiotic Therapy
2.2. Elevation Left hand
2.3. Monitor puncture sites
2.4. Monitor pain level
3. Secondary DX: Anxiety Disorder
3.1. Theraputic Interventions
3.1.1. Relaxation Techniques
3.1.2. Teach pursed lip breathing
3.1.3. Guided imagry
3.1.4. Spousal support
3.1.5. Administer PRN meds
4. Safety concerns
4.1. Assist patient to a safer and more comfortable position
4.2. Lower the bed
4.3. Ensure call light is within reach
4.4. Allergy to shellfish
4.5. Ask about known status of dog
5. Cultural Considerations
5.1. Religion: Hindu
5.2. Ethnicity: Indian
6. Medications
6.1. Morphine
6.1.1. Hep lock IV in right hand