Hyponatremia. Left eye swollen due to fall. Patient fell in the shower twice, did not sustain any fracture

nursing

Description

Care plan infos

65-year-old male

Admitted Jan 27

Admission diagnosis: Hyponatremia. Left eye swollen due to fall. Patient fell in the shower twice, did not sustain any fracture

 

Other admission notes

Patient complained of fatigue, recent weight loss, fever and night sweat

 

Medical history

Enlarge prostate, myocardial infarction, chronic back pain, schizophrenia. Also have history of cocaine use

 

Vitals

Height 67”

Weight 67kg

BMI 23.13

Awake and alert X3

 

BP 124/71

Pulse 83

Spo2 97%

Respiratory 18

Temperature 98.3

 

Urine output 250 ml recorded at 9.30am

Bowel movement at 11:15am (black tarry) about 200 ml

 

 

Pulse 2+

Clear bilateral

No allergies

Sodium 128

Wbc 10.07

Hemoglobin 6.9

Hematocrit 20.6

Potassium 3.8

Chloride 97

Calcium 7.3

Glucose 86

BUN 18

Creatinine 1.07

Co2 26

 

Medications

3 units of blood day 1 of admission

Potassium

Sodium chloride

Lovenox

Magnesium

Methocarbamol

Tramadol

Aspirin

 

Other notes

On regular diet

 

Instruction Files

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