BN-CM/CP-18
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Location (Where are the symptoms located? Are they local or do they radiate?) – arm, face, chest |
Arms, face, chest |
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Duration (When did it start? How long has this problem existed? Is it getting worse? Changing?) |
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Timing (When does it occur? Night or day? At work? etc.) |
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Quality (Characteristics such as constant, sharp, dull, sore) – Sharp, contant |
Sharp, Constant |
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Severity (How bothersome is the problem? Can you sleep, work, etc?) - Significant |
Significant |
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Describe this illness/injury related to how and where this problem began. 16-year-old restrained single passenger involved in MVA today. Fractures of both arms, ribs and burns to 30% of her body. Driving the family car home from a part-time job when she lost control and crashed into a wall. The car exploded into flames. A passerby quickly reported the accident, and fast action by the EMS saved her life
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16 year old restrained single passenger involved in MVA today. Fractures of both arms, ribs and burns to 30% of her body. Driving the family car home from a part-time job when she lost control and crashed into a wall. The car exploded into flames. A passerby quickly reported the accident, and fast action by the EMS saved her life. |
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What makes this problem worse or better? |
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Signs and Symptoms Red, draining wounds of face, chest, and arms. Swelling of tissue, Severe pain in areas of burns and fractures.
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Red, draining wounds of face, chest and arms. Swelling of tissue, Severe pain in areas of burns and fractures. |
Allergies
Peanuts Date allergy noted: 04/28/2002 difficulty breathing
Primary Concern: Multiple fractures and burns
The Patient Summary is read only! To add or edit data you must open another page by clicking the appropriate tab to the left.
Vital Signs
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01/16/2022 1328 |
01/17/2022 1328 |
01/18/2022 0728 |
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Heart Rate |
110 |
112 |
98 |
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Blood Pressure |
110/76 |
100/65 |
105/65 |
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Respirations |
22 |
20 |
18 |
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Temperature |
100.1°F (Tympanic) |
100.6°F (Tympanic) |
98.6 (Tympanic) |
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SpO2 (%) |
98% |
96% |
98% |
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Pain |
8 |
4 |
3 |
Allergies
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Allergy |
Date Noted |
Reaction |
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Peanuts |
04/28/2002 |
difficulty breathing |
Orders
Type of order to view:
All Diet Medication Nursing/Other Orders
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01/16/2022 1328 |
VANCOMYCIN Written order Dose/Frequency: 1000 mg Daily Rate: 200 mL/hour Duration: 10 Route: IVPB Start Date: 01/16/2022 1328 End Date: |
01/17/2022 1328 - Given 1000mg 01/16/2022 1328 - Given 1000mg
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Active |
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01/16/2022 1328 |
Insert Intermittent Infusion Device (saline lock, med lock, hep lock) Written order Frequency: Once Start Date: 01/16/2022 1328 |
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Active |
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01/16/2022 1328 |
HYDROMORPHONE Written order Dose/Frequency: 4 mg PRN Route: IV Start Date: 01/16/2022 1328 End Date: |
01/18/2022 0128 - Given 1mg 01/17/2022 1828 - Given 1mg 01/17/2022 1028 - Given 2mg 01/17/2022 0428 - Given 2mg 01/16/2022 2228 - Given 2mg 01/16/2022 1828 - Given 2mg 01/16/2022 1528 - Given 2mg 01/16/2022 1328 - Given 2mg Hydromorphone 2-4 mg IV every 1 hour PRN for pain |
Active |
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01/16/2022 1328 |
Diet-Clear liquids Written order Frequency: Continuous Start Date: 01/16/2022 1328 |
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Active |
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01/16/2022 1328 |
Consult-Wound Care Written order Frequency: Once Start Date: 01/16/2022 1328 |
Wound dressing changes per wound nurse recommendation |
Active |
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01/16/2022 1328 |
0.9% SODIUM CHLORIDE (NACL) Written order Dose/Frequency: Continuous Rate: 250 mL/hour Route: IV Start Date: 01/16/2022 1328 End Date: |
01/16/2022 1328 - Started Maintain systolic BP above 100 mmHG |
Active |
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Labs
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Lab |
Range |
01/18/2022 0728 |
01/16/2022 1328 |
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Hematology |
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White blood count (WBC) (x th cells/μL) |
4.0-10.0 |
12.9 |
10.3 |
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Red Blood Cell (mil/uL) |
female-4.00-5.20 male-4.50-5.90 |
3.5 |
3.97 |
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Hemoglobin (g/dL) |
male-13.5-17.5 female-12-16 |
10.5 |
11.4 |
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Hematocrit (%) |
male-42-54 female-37-47 |
32 |
36 |
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Mean corpuscular volume (MCV) (fL) |
80–100 fL Pediatric: |
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Mean corpuscular hemoglobin (MCH) (g/dL) |
26–35 g/dL |
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Mean corpuscular hemoglobin concentration (MCHC) (gdL) |
32–36 g/dL |
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Platelet count (x th/μL) |
150–350 x th/μL |
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293 |
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Neutrophils |
40%-60%, 2500-8000 |
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Lymphocytes |
20%-40%, 1000-4000 |
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Monocytes |
2%-8%, 100-700 |
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Eosinophils |
1%-4%, 50-500 |
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Basophils |
0.5%-1%, 25-100 |
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Band |
0%-3% |
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Absolute Neutrophil Count (ANC) (cells/mm3) |
1500-8000 |
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Chemistry |
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Glucose (mg/dL) |
fasting---60–110 mg/dL nonfasting--60-140mg/dL |
98 |
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Urea nitrogen (BUN) (mg/dL) |
8–20 mg/dL |
25 |
22 |
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Creatinine (mg/dL) |
0.7–1.3 mg/dL |
1.2 |
1.4 |
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Bun/Creatinine Ratio |
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19 |
20 |
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Sodium |
136–145 mEq/L |
140 |
142 |
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Potassium (mEq/L) |
3.5–5 mEq/L |
3,8 |
3.6 |
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Chloride |
98-106 mEq/L |
102 |
100 |
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Calcium |
8.7 - 10.7 mg/dL |
9.1 |
8.9 |
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Magnesium (mEq/L) |
1.5-3 mEq/L |
2.1 |
2.0 |
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Phosphate |
2.5-4.5 mg/dL |
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Total CO2 (mEq/L) |
23-29 mEq/L |
26 |
24 |
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AST (SGOT) (units/L) |
3-44 units/L |
42 |
44 |
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Alkaline phosphatase (ALP) (U/L) |
36–92 U/L |
56 |
45 |
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Total Protein (g/dL) |
6.3-8.2 |
6.0 |
5.9 |
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ALT (SGPT) (units/L) |
0-40 units/L |
36 |
35 |
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Albumin (g/dL) |
3.5–5.5 g/dL |
3.3 |
3.4 |
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Bilirubin: Total (mg/dL) |
0.3–1.2 mg/dL |
1.0 |
1.0 |
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Total Calcium (mg/dL) |
<10 days: 7.6- 10.4 mg/dL Umbilical: 9.0 - 11.5 mg/dL 10 days - 2 years: 9.0 - 10.6 mg/dL Child: 8.8 - 10.8 mg/dL Adult: 9.0 - 10.5 mg/dL (Decreases with age) |
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Serum bicarbonate (HCO3) |
Adult/child: 21-28; Newborn/infant: 16-24 (mEq/L) |
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