Name: Chelsea Aboyo
Age: 42 years
Provider: B. Thorton MD
Allergies: prednisone
Code Status: Full Code
Admit Wt: 280 lbs (127.3 kg)
BMI: 46.6
Flowsheets
Collaborative Care
Other
COLLABORATIVE CARE
Date Temp HR RR BP SpO2 O2
9/19 2300 97.0 °F
(36.1 °C), oral 130 34 160/80 99% RA
Medical History: Asthma, type 1 diabetes, anemia
Social History: Smokes 0.5 packs of cigarettes daily for 10 years
Neuro/Cognitive: Alert, oriented to person, place, time, and situation. Speech clear but rapid. Needs redirection to complete instructions. +tingling in bilateral hands and feet.
Cardiovascular: S1 and S2 sounds present. Denies chest pain. Electrocardiogram shows sinus tachycardia.
Respiratory: Breathing rapid. Equal chest rise and fall.
Genitourinary: burning upon urination and “odd” smelling urine
Pain: Rates 0/10 pain. “I just feel anxious.”
9/20 0010 Nursing Note: Instructed client on collection process of urine sample, urine is sent to the lab for completion of urine pregnancy test, urinalysis, and urine drug screen.
9/20 0030 Nursing Note: Client visibly upset after nurse addresses client behaviors and asks about past trauma and anxiety triggers. Client becomes withdrawn.
Prescriptions:
Start peripheral IV.
CBC, BMP, troponin, urinalysis, urine toxicology, urine pregnancy screening.
Chest x-ray.
EKG.
Lorazepam 2 mg intramuscular injection once.
Alprazolam 0.5 mg by mouth once.
Labetalol 5 mg IV push once.
Mental Health Consult
Reason for consult: Client experiencing anxiety, panic disorder
Assessment: Client is hyperventilating, stating anxiety is out of control. Client is tearful. Client denies intention to injure self or others.
Recommendations:
Reassure the client of safety.
Leave the client in the room so she can calm down.
Encourage the client to talk about what triggered her anxiety.
Decrease stimuli in the room.
Use brief and direct communication.
9/19 2300 Mental Health Consult
Reason for consult: Client experiencing anxiety, panic disorder
Assessment: Client is hyperventilating, stating anxiety is out of control. Client is tearful. Client denies intention to injure self or others.
Recommendations:
Reassure the client of safety.
Leave the client in the room so she can calm down.
Encourage the client to talk about what triggered her anxiety.
Decrease stimuli in the room.
Use brief and direct communication.
