EHR assignment part 2: John Miller, was hospitalized a month ago… EH

EHR assignment part 2: John Miller, was hospitalized a month ago… EHR assignment part 2: John Miller, was hospitalized a month ago for a left subdural hematoma. He underwent a neurosurgical procedure to drain the blood and recovered well with no complications and no residual neurological deficits. He has come back to the hospital emergency department complaining of episodes of headaches and dizziness.   EHR go part 1 information:  A 57 year old male (John Miller) presents to the ED via ambulance after sustaining a fall and head injury down a flight of 12 stairs. He presents to triage with a laceration to his forehead and guarding his left shoulder with a possible fracture. At triage is it noted that nurse he is confused to place and time. He was only opening his eyes when the nurse asked him to. He had power to all limbs. His pupils were equal, round and reactive. His blood pressure was slightly elevated, otherwise vital signs were within normal limits. The Emergency physician ordered a CT scan of the head for John. The scan results demonstrated a left subdural hematoma and requires admission to hospital. He has been transferred to the 6A – Neurology Unit and you have been assigned to his care. You arrive to his room and assist the porters in transferring him from the stretcher to bed.  through analysing the case study answer these s below Scheduled MedsHydrochlorothiazide 12.5 MG Oral Tablet – Dose: 12.5MGDAILY (0800)Active02/19/202208:18 Scheduled MedsNicorette 2 MG Chewing Gum – Dose: 2mgAS DIRECTED PRNActive LaboratorySerum cholesterol and triglyceride levelsONCEActive DieteticsLow Sodium DietThree times a dayActive LaboratorySerum CreatinineONCEActive DiagnosticsECGONCEActive Scheduled MedsAPO-RAMIPRIL (Ramipril) 2.5mg Tablet – Dose: 2.5MGDAILY (0800)Active LaboratoryurinalysisONCEActive Scheduled MedsAcetaminophen 325 MG Oral Tablet [Tylenol] – Dose: 650mgEvery 4 hoursActive Scheduled MedsPhenytoin 100 mg (Dilantin) – Dose: 300mgDAILY (1000)Discontinued1. Identify the risk factors that have contributed to John’s new diagnosis. (1 mark per risk factor = 3 marks total)2. Review John’s vital signs. Is treatment required for his blood pressure? Explain why or why not. (1 mark)3. Review the physician orders, on the Order tab. Select any 6 orders. What is the rationale for each order? Remember when you are asked to provide rationale for an order you are being asked to answer why is this ordered? (12 marks total – 1 mark for each order identified, 1 mark for each rationale provided).4. Has John been prescribed any antihypertensive medications? If so, which one(s) and why has this medication been prescribed for John? (4 marks)   Health Science Science Nursing PNH 301 Share EmailCopy link Comments (0)

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