Brief Background: 58 year old homeless man brought into the ER by paramedics 3 hours ago after

reports that he was having a seizure in an alleyway. (He also had a seizure shortly after arrival
Assessment Problem Statement Goals Actions Evaluation

T 100.6, P 110, R 28, BP 108/62 %sat 80 on 4L/min Seizure activity, alcoholism Emesis on tshirt Bronchovesicular breath sounds and course crackles WBCs 18.5 with 80% polys, 15% bands (left shift) Wet nonproductive cough

Hypoxia (oxygenation impaired) RT Probable aspiration pneumonia AEB CXR, refractory hypoxia, emesis on Tshirt Hx of alcoholism and witnessed seizure. Abnormal breath sounds

W/in 12 hours temp will be normal and stay normal. w/in 24 h, white count will begin to trend toward normal w/in 24 hours pt will be hydrated (serum Na+, BUN, Creatinine trend down) and will be mobilizing sputum W/in 12 hours will require only nasal prongs and 46 L/min oxygen

Begin ralley bag over 8 hours then D5NS at 100 ml/hour Encourage po fluids when fully awake Respiratory therapy protocol q6h (nebulization) Suction patient and send sputum for gram stain and C&S Cephtriaxone and levofloxacin as ordered IV Oxygen (40% mask) Hourly rounding when on clinical unit, VS q4h and prn.