I have one question: Write one SOAPIE is following this pateint's chart.
Scenario: Juan Reyes has now been hospitalized for one week. Blood cultures were positive for Streptococcus pneumonia; Juan's doctor also did a spinal tap on Juan which was positive for the same organism. His medical diagnosis is pneumococcal meningitis. He was started on an antibiotic medication called Vancomycin 1 gm to be given every 12h and ceftazidime 2 gm every 8h intravenously. Mr. Reyes was confused initially when he was placed in respiratory isolation, but now, with negative cultures, he has been transferred out of isolation to a medical floor room.
You are assigned to care for Juan this shift and you enter his room:
l His facial skin is warm, pink, and dry.
l He says, "That IV site in my right arm sure hurts today."
l His oral temperature is 98.8, R=18, P=80, BP 110/80
l His breathing is regular and his lung fields have normal-sounding air flow on both sides of the back and front of his chest.
l Skin around the IV catheter is red, not swollen, but tender to touch.
l The IV is dripping at an 80cc per hour rate according to the meter in the IV AC IV pump.
l Mr. Reyes says that he no longer has a headache, neck ache, or photophobia.
l He eats only a small amount of breakfast saying "I'm still not very hungry, my stomach gets upset with heavy foods like fried eggs and panckes."
l He get up to the bathroom with your help and urinates clear, straw-colored urine.
PiscesY
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Thank you so much!
You give me answer so comprehensive. But my teacher give me the answer still diffrent yours. So I still feel confuse.
Anyway, I just want to say thank you,because you still teach me a lot.